(Medicare Claims Processing Manual)

20.6.5 - Capped Rental DME Furnished Prior to January 1, 2006  (Rev. 1502; Issued:  05- 09-08; Effective/Implementation Date:  06 -09-08)  This section addresses situations where the beneficiary did not elect the purchase option described in section 30.5.2 of Chapter 20 for capped rental DME for which the first rental month occurred prior to January 1, 2006.  In accordance with section 30.5.4 of Chapter 20, the supplier that provides the item in the 15th month of the rental period is responsible for supplying the equipment and for maintenance and servicing after the 15- month period.  This requirement is not eliminated by any requirement under the competitive bidding program and applies to both contract and noncontract suppliers without regard to their grandfathered status.  (See section 50.1 of Chapter 20).   20.7 - Use of Advanced Beneficiary Notice (ABNs)  (Rev. 1502; Issued:  05- 09-08; Effecti ve/Implementation Date:  06 -09-08)  Except where an exception applies, a beneficiary has no financial liability to a noncontract supplier that furnishes an item included in the competitive bidding program for a CBA, unless the beneficiary has signed an Advance Beneficiary Notice (ABN).   However, if a noncontract supplier in a CBA obtains a signed ABN indicating that the beneficiary was informed in writing prior to receiving the competitively bid item or service that there would be no payment by Medicare due  to the supplier's non- contract status, the noncontract supplier may charge the beneficiary for the item or service.  In this circumstance, non- contract suppliers cannot bill Medicare and receive payment for the competitively bid item or service.   An ABN i s a written form provided by the supplier and signed by the Medicare beneficiary in which the beneficiary agrees to pay out of pocket for charges not paid for by Medicare.  See Chapter 30 -  Financial Liability Protections of this manual for general instruc tions relating to ABN requirements.  In addition to the other uses of an ABN as defined in Chapter 30, an ABN informs a beneficiary before he or she receives specified items or services from a noncontract supplier that Medicare will probably not pay for the specified items or services for that particular beneficiary on that particular occasion if furnished by a noncontract supplier.  30 - Contract Supplier Responsibilities  (Rev. 1502; Issued:  05- 09-08; Effective/Implementation Date:  06 -09-08)  30.1 - Comp liance with Laws and Regulations  (Rev. 1502; Issued:  05- 09-08; Effective/Implementation Date:  06 -09-08)  A contract supplier, and its affiliated companies and subcontractors, must comply with all applicable Federal and State laws and regulations including, without limitation, the final rule on Competitive Acquisition for Certain DMEPOS and Other Issues that appeared in the Federal Register on April 10, 2007 (72 Fed. Reg. 17992) and 42 CFR, Part 414, Subpart F.  A contract supplier must also comply  with any applicable State licensing requirements pertaining to its functions as a contract supplier.  30.2 - Requirement to Maintain Medicare Billing Privileges and Accreditation  (Rev. 1502; Issued:  05- 09-08; Effective/Implementation Date:  06 -09-08)  A contract supplier must satisfy the enrollment standards specified in 42 CFR 424.57(c), meet applicable quality standards (both general quality standards and product specific quality standards) developed by CMS in accordance with section 1834(a)(20) of the  Act, and be accredited by a CMS -approved accreditation organization for the duration of the contract period.  Contract suppliers must maintain appropriate enrollment and accreditation throughout the term of their contracts.  The contract supplier must not ify the CBIC in writing at the US postal or certified (physical) mailing address identified in the suppliers contract within five (5) business days of any changes to its Medicare billing privileges or accreditation status.   30.3 - Servicing the Entire Geo graphic Area of a CBA  (Rev. 1502; Issued:  05- 09-08; Effective/Implementation Date:  06 -09-08)  A contract supplier must agree to furnish all items under its contract to any beneficiary who maintains a permanent residence in or visits a CBA and requests th ose items from the contract supplier unless an exception applies.  There are two exceptions.  First, SNFs or NFS that become specialty suppliers only furnish competitive bidding items to their residents.  Second, individual network members are not required to provide services through the entire geographic of a CBA.  However, the network as a whole must provide services throughout the entire geographic area of a CBA.   30.4 - Prescription for Particular Brand, Item, or Mode of Delivery  (Rev. 1532, Issued: 06- 11-08, Effective: 07- 01-08, Implementation: 07- 07-08)  Contract suppliers are not required to furnish a specific brand name item or mode of delivery to a beneficiary unless prescribed by a physician or treating practitioner  to avoid an adverse medical outcome. A physician or treating practitioner (that is a physician assistant, clinical nurse specialist, or nurse practitioner) may prescribe, in writing, a particular brand of a competitively  bid item or mode of delivery for an item if he or she determines that the particular brand or mode of delivery is necessary to  avoid an adverse medical outcome for the beneficiary. The physician or treating practitioner must document in the beneficiarys medical record the reason why the specific brand or mode of delivery is necessary to avoid an adverse medical outcome.  This documentation should include the following:    The products brand name or mode of delivery;    The features that this product or mode of delivery has versus other brand name products or modes of delivery; and   An explanation of how these features are necessary to avoid an adverse medical outcome.   If a physician or treating practitioner prescribes a particular brand or mode of delivery t o avoid an adverse medical outcome, the contract supplier must either:   (1)  Furnish the particular brand or mode of delivery as prescribed by the physician or treating practitioner;   (2)  Consult with the physician or treating practitioner to find another  appropriate brand of item or mode of delivery for the beneficiary and obtain a revised written prescription from the physician or treating practitioner; or   (3)  Assist the beneficiary in locating a contract supplier that can furnish the particular brand of item or mode of delivery prescribed by the physician or treating practitioner.  Any change in the prescription requires a revised written prescription for Medicare payment. A contract supplier is prohibited from submitting a claim to Medicare if it furnishes an item different from that specified in the written prescription received from the beneficiarys physician or treating practitioner.   30.5 - No Discrimination Against Beneficiaries  (Rev. 1502; Issued:  05-09- 08; Effective/Implementation Date:  06 -09-08)  42 CFR 414.422(c) specifies that contract suppliers may not discriminate against beneficiaries under the Medicare DMEPOS Competitive Bidding Program.  The items furnished by a contract supplier must be the same items that the contract supplier makes  available to other customers.  All products provided must meet product specifications identified by the HCPCS coding system.  30.6 - Quarterly Reports  (Rev. 1502; Issued:  05-09- 08; Effective/Implementation Date:  06 -09-08)  The contract supplier must submit quarterly reports to the CBIC using Form CMS-10169C, The Medicare DMEPOS Competitive Bidding Program Contract Supplier Quarterly Report (OMB No. 0938- 1016), which can be accessed at the CBIC Web site at: http://www.dmecompetitivebid.com.    The contract supplier must submit to the CBIC a quarterly report no later than ten (10) calendar days after each of the following dates:  March 31, June 30, September 30, and December 31.  If the due date for a particular quarterly report falls on a Saturday, Sunday, or Federal holiday, the report is due on the next business day.  As provided in Form CMS-10169C, each quarterly report must disclose the following regarding each item specified by CMS that was furnished under its contract during the calendar quarter immediately preceding the reports due date:  the items HCPCS code; the approximate number of items furnished; the manufacturer of the item; the items model name; and the items model number.  The contract supplier must submit each quarterly report to the CBICs regular or certified mailing address identified in its contract.   When the contract supplier submits the required quarterly reports, it should also review the Medicare Sup plier Directory, found at http://www.medicare.gov (in the section entitled Find Suppliers of Medical Equipment in Your Area) to determine whether the suppliers information is current, including the lists that indicate which manufacturers products that the contract supplier makes available to beneficiaries.  If the information is not current, the contract supplier should submit current information to the CBICs regular or certified mailing address identified in its contract within ten (10) business days of the close of each quarter.  30.7 - Reporting Change of Ownership (CHOW)  (Rev. 1502; Issued:  05-09- 08; Effective/Implementation Date:  06 -09-08)  Pursuant to 42 CFR 414.422(d)(2), CMS may award a contract to an entity that merges with, or acquires, the contract supplier if (1) the successor entity meets all requirements applicable to contract suppliers for the competitive bidding program(s) to which the contract suppliers contract applies; and (2) the successor entity submits to CMS the documentation described in 42 CFR 414.414(b)-(d) if that documentation has not previously been submitted by the successor entity or the contract supplier that is being acquired, or is no longer current.  The documentation required by 42 CFR 414.414(b)- (d) is necessary to substantiate compliance with basic eligibility requirements, quality standards, accreditation requirements and financial standards.  The successor entity that is acquiring the assets of the contract supplier mu st also submit to CMS, at least 30 calendar days before the anticipated effective date of the change of ownership, an executed novation agreement acceptable to CMS.  The novation agreement must state that the successor entity will assume all obligations un der the contract.   If a new entity will be formed as a result of the merger or acquisition, the existing contract supplier must submit to CMS for review, at least 30 calendar days before the anticipated effective date of the change of ownership, its final draft of a novation agreement stating that the new entity will assume all obligations under the contract.  With the final draft novation agreement, the existing contract supplier must submit the documentation described in 42 CFR 414.414(b)- (d) if the information previously submitted by the contract supplier is no longer current.  The new entity must also submit to CMS, within 30 calendar days after the effective date of the change of ownership, an executed novation agreement acceptable to CMS stating that it will assume all obligations under the contract.  The new entity must meet all requirements applicable to contract suppliers for the applicable competitive bidding program.  The following chart illustrates the CHOW requirements needed to remain a contract supplier described above.   Entity  Requirement  Number of Days to Meet Requirement  Contract Supplier Only  The existing contract supplier must notify CMS if it is negotiating a CHOW.  60 calendar days before the anticipated date of the change.  If a new entity will be formed as a result of the merger or acquisition, the existing contract supplier must submit to CMS, its final draft  of a novation agreement as described in 414.422(d)(2)(iii).  At least 30 calendar days before  the anticipated date of  the CHOW . Successor Entity or New Entity  The successor entity or new entity must submit to CMS the documentation in 414.414(b)-(d), if not submitted previously by the successor or the contract supplier or if no longer current. Duplicates of previously submitted information need not be submitted if that information is still current.  Within 30 calendar days prior  to the anticipated effective date of the CHOW.  Entity  Requirement  Number of Days to Meet Requirement  Successor Entity Only  The successor entity that is acquiring the assets of the existing contract  supplier must submit to CMS, a signed novation agreement  acceptable to CMS, stating that it will assume all obligations under the contract.  At least 30 calendar days before  the anticipated effective date of the change of ownership.  New Entity Only  The new entity must submit to CMS an executed novation  agreement acceptable to CMS.  Within 30 calendar days after  the effective date of the CHOW.  NOTE:  Successor and new entities must meet all requirements applicable to contract suppliers for the applicable competitive bidding program.   Any communication with CMS regarding the change of ownership must be in writing and mailed to the appropriate address designated in the contract.  30.8 - Submission of Claims  (Rev. 1502; Issued:  05-09- 08; Effectiv e/Implementation Date:  06 -09-08)  A contract supplier must submit Medicare claims for payment in accordance with rules in this chapter.