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Serial Claims

First Claim Review Initiative for Serial Claims

In July 2018, CMS published an MLN articleExternal PDFregarding a new initiative to increase the consistency of medical review decisions when the same item/supply is provided to the same beneficiary on a recurring basis (serial claims). CMS considers serial claims to be claims that are so closely related to one another that the same payment decision should be applied to each claim. In general, serial claims are for the same HCPCS code and same beneficiary.

Initial Claim

The DME MACs are instructed to perform a pre-payment medical record review on the initial claim, and based on the results of the medical review they will do the following:
  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.

DME MACs update the Certificate of Medical Necessity (CMN) 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. This change will also ensure 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, in instances where the medical necessity decision is applicable to other claims in the series.

New or Additional Documentation Submission

How To Submit Additional Documentation on a subsequent claim in a series

    1. Add the documentation to the claim if billed on paper or if billed electronically add the following indicators:
      • FX (i.e. fax), BM (i.e. mail), EL (i.e. electronic esMD documents using X12 Standards [6020x12 275]), or FT (i.e. file transfer esMD documents in PDF XDR format) to the Paperwork (PWK02) indicator, and
      • “Serial” to the Note Field (NTE02).
    2. Complete a PWK coversheetPDF to place on top of your documentation:
      Fax to 1.615.782.4511, or
      Mail it to CGS Medicare, P.O. Box 20007, Nashville, TNĀ  37202, or
      Send via esMD
    3. Send the additional documentation timely. To ensure the additional documentation is submitted on time, the DME MAC should receive it within 7 days (if faxed or via esMD) or 10 days (if mailed). The claim will be processed based on existing information if the additional documentation is not received within these timeframes.

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

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.

Specifically, the DME MACs will apply this process to:

The Serial Claims 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

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