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Serial Claims

First Claim Review Initiative for Serial Claims

In July 2018, CMS published an MLN articleExternal PDF regarding a new initiative intended to reduce provider burden, contractor burden, and appeals by increasing the consistency of medical review decisions when the same item/supply is provided to the same beneficiary on a recurring basis (serial claims). The DME MACs perform a prepayment medical record review on the 1st claim and then, based on the results of the medical review:

  1. Pay subsequent claims in the series after passing existing validation edits, OR
  2. Deny subsequent claims in the series unless the provider submits additional documentation with the subsequent claim line.

The new processes were implemented as described below:

Items/supplies that are not included in Addendum B may still be reviewed following normal processes. The new serial claims processes will be used in conjunction with existing CGS Medical Review processes.

Serial Claims Initiative for Appeals

The Durable Medical Equipment (DME) Medicare Administrative Contractor (MAC) Appeals workgroup collaborated with the Centers for Medicare & Medicaid Services (CMS) in development of the Serial Claims Initiative to improve the way in which claims that are billed in a series are adjudicated. A serial claim is defined as capped rental equipment and certain Inexpensive and Routinely Purchased (IRP) items that are paid on a monthly rental basis not to exceed a period of continuous use of 13 months or 36 months (oxygen).

This initiative began in April 2017, and provides a process to connect a favorable determination on a serial claim to other claims in the series that were denied for same or similar reasons. If the related claims are currently pending at the Qualified Independent Contractor (QIC) or the Office of Medicare Hearings and Appeals (OMHA), the DME MAC will communicate the favorable decision so it may be considered when adjudicating related appeals pending at those levels.

The initiative also allows future claims in the series to pay, and it includes data analysis of all favorable serial claim appeal decisions made over the past 3 years, in an effort to identify pending appeals in the series that may be eligible for resolution. In addition, the initiative enhances the supplier's experience by ensuring that items that have been subject to medical review and have been determined to meet medical necessity standards will continue to be paid consistently for the duration of the rental period, thus reducing the volume of new denials and subsequent appeals, as well as improving the adjudication process for currently pending appeals.

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