CMS Eases Adjudication Process for Serial Claims

DME MACs will change appeals of recurring claims for capped rental items and certain inexpensive and routinely-purchased items.

• By David Kopf
• Apr 27, 2017

The American Association for Homecare reports that after years of effort by its Regulatory Council, CMS has made significant changes to improve the processing and adjudication of serial claims for capped rental items and certain inexpensive and routinely purchased DME.

The good news comes after Kim Brummett, vice president of regulatory affairs for AAHomcare, and the association's Regulatory Council have spent years working with CMS leadership to address the issue, according to an association statement.

“… We are pleased to hear this announcement,” the statement read. “Recently, the Council met with CMS leadership and discussed the challenges with serial claims and their effect on suppliers and the appeals backlog. This announcement will provide welcome relief to suppliers.”

Complete details on the changes are available in a a CMS statement. Key changes include:

• CMS recently directed the DME MACs to change the process used to adjudicate appeals of serial claims. Once the reason for denial for one claim in a series is resolved at any appeal level, the DME MACs will identify other claims in the same series that were denied for the same or similar reasons, and take that determination into consideration when adjudicating such claims. 
• The DME MACs will also communicate the favorable decisions to the DME QIC and the Office of Medicare Hearings and Appeals (OMHA) to consider when adjudicating related appeals pending at those levels. 
• CMS has also instructed the DME MACs to update the Certificate of Medical Necessity (CMN) in the ViPS Medicare System (VMS), when appropriate, to reflect when a favorable decision has been rendered for a serial claim, allowing future claims in the same series to pay without requiring suppliers to continually resubmit evidence.
• CMS instructed the DME MACs to perform data analysis of all favorable serial claim appeal decisions made over the past three years, in an effort to capture all currently pending appeals in the series that could be included in this initiative. Suppliers do not need to take any action and should not reach out to the DME MAC within their jurisdiction to request that their appeal be considered for this initiative.