The Pennsylvania Department of Public Welfare through the Comptroller’s Office has completed a special review of durable medical equipment (DME) rentals that paid in error without prior authorization after three months rental as required by Medical Assistance (MA) Program policy.
Claims in the review include dates of service January 1, 2011 through June 30, 2012.
The department has determined that some of these claims paid in error because they were inaccurately coded as having Medicare Advantage coverage even though the beneficiary did not. This is a violation of the MA Program policy.
According to MA Regulations, Chapter 1101.67(a) Prior Authorization, “Medical services and items that require prior authorization are designated in Chapter 1150 (relating to MA Program payment policies) and the MA Program Fee Schedule and may also be addressed in the specific provider chapters. Providers shall follow the instructions in the provider handbook for processing prior authorization requests.” The 837 Professional/CMS-2500 Claim Form Handbook, Section 7.1.1 – Services and Items Requiring Prior Authorization, states, “Prior authorization is required after three months of rental on any item.”
The department has voided those claims that paid inappropriately under the Fee-for-Service Program for beneficiaries whose claims were inaccurately coded as having Medicare Advantage coverage and paid greater than the 3 month time period without prior authorization. Claims have been reprocessed during this cycle and are identified by ICN ranges: 501328004, 501328003, 501328002, 501329001, 501329002, 501329009, 501329010, 501329011, and 501324002.
Please note that the adjustment of these claims does not guarantee payment. If there are other conditions or billing errors associated with these claims, you will receive error status codes specific to those conditions or errors, which may affect payment.
For more information go to: http://www.dpw.state.pa.us/publications/forproviders/remittanceadvicealertspromisebannerpages/P_035551