(Medicare Claims Processing Manual)

To determine the Part B payment to a nominal charge provider other than a nominal charge HHA, A/B MACs (A) and (HHH)  subtract any unmet Part B deductible from the lower of the actual charge or the fee schedule amount and multiply the remainder by 80 percent.  This is the final payment.  4. Patient Liability to a HHA Other Than a Nominal Charge HHA   To determine the patient liability to a HHA other than a nominal charge HHA under Part B, A/B MACs (HHH) subtract any unmet deductible from the lower of the actual charge or fee schedule amount and multiply the remainder by 20 percent.  The result, plus the unmet deductible is the patient's liability.  If the item or service is covered under a plan of care, the deductible does not apply.  5. Patient Liability to a Nominal Charge HHA   To determine patient liability to a nominal charge HHA under Part B, A/B MACs (HHH) subtract any unmet deductible from the fee schedule amount and multiply the remainder by 20 percent.  The result, plus the unmet deductible is the patient's liability.  If the item or service is covered under a Plan of Care, the deductible does not apply.  6. Patient Liability to a Provider Other Than a HHA   To determine patient liability to a provider other than an HHA (including nominal charge providers other than a HHA), A/B MACs (A)  subtract any unmet deductible from the actual charge and multiply the remainder by 20 percent.  The result, plus the unmet deductible is the patient's liability.  Coinsurance is applied as applicable.   The following describes application of deductible and coinsurance on HHA bills by bill type:   a. Patient Under Part B Plan of Treatment (Bill Type 32X)   No deductible applicable; and  No coinsurance applicable   Exception:   Coinsurance applies on DME and orthotic/prosthetic claims.  b. Patient Under Part A Plan of Treatment (Bill Type 33X)   No deductible applicable; and  No coinsurance applicable   Exception:  Coinsurance applies on DME and orthotic/prosthetic claims.  c. Patient Not Under Plan of Treatment, Part B Medical and Other Health Services and Osteoporosis Injections (Bill Type 34X)    Deductible applies; and   Coinsurance applies   The following examples illustrate how to calculate provider payment and patient liability in various situations.  The examples, like the preceding rules for HHAs, address items and services not under a Plan of Care and, therefore, include deductible applic ation.  The Note following each HHA example addresses items and services obtained under a Plan of Care and, therefore, do not address deductible application.  EXAMPLE 1:   CLAIM CONTAINING ONLY ORTHOTIC/PROSTHETIC CHARGES   $200.00 Orthotic/prosthetic charges  $140.00 Orthotic/prosthetic fee schedule amount  $100.00 Part B deductible to be met   To determine the payment to all providers (other than nominal charge HHAs) apply the following steps:   Step 1:  Determine the lower of the actual charge or the fee schedule amount:  $140.00 (do not apply the provider's interim rate)  Step 2:  Subtract any unmet Part B deductible from the amount determined in Step 1:  $140.00 - $100.00 = $40.00  Step 3:  Apply 80% to the amount determined in Step 2:  $40.00 X 80% = $32.00   The Part B payment to the provider in this example is $32.00   To determine payment to nominal charge HHAs apply the following steps:   Step 1:  Subtract any unmet deductible from the fee schedule amount: $140.00 - $100.00 = $40.00  Step 2:  Apply 80% to the amount determined in Step 1: $40.00 x 80% = $32.00   The Part B payment to the nominal charge HHA in this example is $32.00  NOTE:   If the item or service is covered under a Home Health Plan of Care, the payment is determined the same way, except no deductible is applicable.  In the above examples the payment would be $112.00 ($140.00 x 80%).   To determine beneficiary liability to providers other than HHAs apply the following steps:   Step 1:  Subtract any unmet Part B deductible from the actual charge:  $200.00 - $100.00 = $100.00  Step 2:  Multiply the amount determined in Step 1 by 20% coinsurance: $100.00 x 20% = $20.00  Step 3:  Add the result of Step 2 to the unmet deductible: $20.00 + $100.00 = $120.00   The beneficiary's liability in this example is $120.00.  ($100.00 Part B deductible and $20.00 coinsurance.)   NOTE:   If the item of service is covered under a Home Health Plan of Care, the beneficiary's liability is determined the same way, except no deductible is applicable.  In this example, the beneficiary's liability would be $28.00 ($140.00 x 20% coinsurance).   EXAMPLE 2:   CLAIM CONTAINING ONLY ORTHOTIC/PROSTHETIC CHARGES - NEGATIVE PAYMENT   $120.00 Orthotic/prosthetic charges  $  80.00 Orthotic/prosthetic fee schedule amount  $100.00 Part B deductible to be met   To determine the payment to all providers (other than nominal charge HHAs) apply the following steps:   Step 1:  Determine the lower of the actual charge or the fee schedule amount:  $80.00 (do not apply the provider's interim rate)  Step 2:  Subtract any unmet Part B deductible from amount determined in Step 1:  $80.00 - $100.00 = -$20.00   Do not apply the 80 percent since the result of Step 2 is a negative amount.  There is no Part B payment to the provider in this example because the result equals a negative payment amount.  A/B MACs (A) or (HHH)  do not take the negative amount of ( -$20.00) from future payments to the provider.   To determine payment to nominal charge HHAs, apply the following step:   Step 1:  Subtract any unmet deductible from the fee schedule amount: $80.00 - $100.00 = -$20.00   Do not apply the 80 percent since the result of Step 1 is a negative amount.  There is no Part B payment to the nominal charge HHA in this example because the result equals a negative payment amount.  A/B MACs (HHH) do not take the negative amount of ( -$20.00) from future payments to the HHA.   NOTE:  If the item or service is covered under a Home Health Plan of Care the payment is determined in the same way, except no deductible is applicable.  In the above examples the payment would be $64.00 ($80.00 x 80%).   To determine beneficiary liability to providers other than HHAs, apply the following steps:   Step 1:  Subtract any unmet Part B deductible from the actual charge: $120.00 - $100.00 = $20.00  Step 2:  Multiply the amount in Step 1 by 20% coinsurance: $20.00 x 20% = $4.00   The beneficiary's liability in this example is $104.00 ($100.00 Part B deductible and $4.00 coinsurance).   The beneficiary's liability to HHAs (nominal charge and other than nominal charge) in this example is $80.00 (the fee schedule amount for nominal charge HHAs or the lower of the fee schedule amount or the actual charge for other than nominal charge HHAs).  The HHA cannot charge the beneficiary the $100.00 deductible since it exceeds $80.00.  $80.00 is credited to the beneficiary's deductible.  The beneficiary's deductible to be met on the next claim is $20.00.  The beneficiary has no coinsurance obligation.  NOTE:  If the item or service is covered under a Home Health Plan of Care, the beneficiary's liability is determined the same way, except that no deductible is applicable.  The beneficiary's liability in this example would be $16.00 coinsurance ($80.00 x 20%).   200 - Automatic Mailing/Delivery of DMEPOS  (Rev. 1, 10- 01-03)  Suppliers/manufacturers may not  automatically deliver DMEPOS to beneficiaries unless the beneficiary, physician, or designated representative has requested  additional supplies/equipment.  The reason is to assure that the beneficiary actually needs the DMEPOS.  DME MAC review should be done on a post -pay basis.   A beneficiary or their caregiver must specifically request refills of repetitive services and/or supplies before a supplier dispenses them.  A supplier may not initiate a refill of an order.  The supplier must not automatically dispense a quantity of suppl ies on a predetermined regular basis.  A request for refill is different than a request for a renewal of a prescription.  Generally, the beneficiary or caregiver will rarely keep track of the end date of a prescription.  Furthermore the physician is not likely to keep track of this.  The suppli er is the one who will need to have the order on file and will know when the prescription will run out and a new order is needed.  It is reasonable to expect the supplier to contact the physician and ask for a renewal of the order.  This is consistent with the DME MAC Supplier Manual for the particular jurisdiction, which states: "The description of the item (on an order) may be completed by someone other than the physician (most commonly the supplier).  However, the physician must review the order and sign and date it to indicate agreement."  Again the supplier must not automatically mail or deliver the DMEPOS to the beneficiary until specifically requested.   The DME MACs inform suppliers of these procedures via their bulletins and training sessions.  These procedures will benefit suppliers by helping to maximize claims processing accuracy, and to reduce the likelihood of a postpayment claim denial because the DMEPOS were not medically necessary.   DME MACs must publish this information on their Web sites and in their bulletins on an annual basis.   210 - CWF Crossover Editing for DMEPOS Claims During an Inpatient Stay  (Rev. 2993, Effective: ASC X12 -  01-01-12, ICD -10 - Upon Implementation of ICD -10; Implementation: ASC X12 -  08-25-14, ICD -10 - Upon Implementation of ICD -10)  I. General Information   A. Background:   In general, the DMEPOS benefit is meant only for items a beneficiary is using in his or her home.  For a beneficiary in a Part A inpatient stay, an institutional provider (e.g., hospital) is not defined as a beneficiarys home for DMEPOS, and so Medicare does not make separate payment for DMEPOS when a beneficiary is in the institution.  The institution is expected to provide all medically necessary DMEPOS during a beneficiarys covered Part A stay.   EXCEPTION:  Medicare makes a separate payment for a full month for DMEPOS items, provided the beneficiary was in the home on the from date or anniversary date defined below.   For capped rental items of durable medical equipment (DME) where the DME supplier submits a monthly bill, the date of delivery (from date) on the first claim must be the from or anniversary date on all subsequent claims for the item.  For example, if t he first claim for a wheelchair is dated September 15, all subsequent bills must be dated for the 15th of the following months (October 15, November 15, etc.).   B. Policy:   If a beneficiary using DMEPOS is at home on the from date or anniversary date, Medicare pays for the DMEPOS for the entire month, even if the from date is the date of discharge from the institutional provider.  If a beneficiary using DMEPOS is in a covered Part A stay for a full month, Medicare does not make payment for the DMEPOS for that month.  For capped rental items, if the covered Part A stay overlaps the anniversary date (from date on the claim), and the beneficiary is not in the covered Part A stay for the entire month, the date of discharge becomes the new anniversary date (from date on the claim) for subsequent claims.  In this situation, the supplier must submit a new claim with the date of discharge as the new anniversary date upon the beneficiarys release from the institution.  Suppliers should annotate the claims, to indicate that the patient was in an institution, resulting in the need to establish a new anniversary date. The CWF:    rejects a DME MAC claim that contain DMEPOS HCPCS codes when the DME MAC claim has a date of service that falls within the inpatient stay;   considers an inpatient stay to include all days prior to the date of discharge;    processes a DME MAC claim that contain DMEPOS HCPCS codes when the DME MAC claim has the same from date equal to the date of inpatient discharge;