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Serial Claims Review Initiative

First Claim Review Initiative for Serial Claims

In July 2018, CMS published an MLN articleExternal PDF regarding 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 Processing

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

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

DME MACs update the system 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

Suppliers should be aware that if a serial claim is denied after a medical record review, subsequent claims in the series will also be denied for the same reason unless additional documentation is submitted to demonstrate that the services are reasonable and medically necessary.

  • If a paper claim is submitted, any additional documentation must be attached to the claim form.
  • If an electronic claim is submitted, the existing PWK process must be followed and the claim must also include the word "serial" in the NTE02 segment. (See CMS Medicare Learning Network (MLN) Matters (MM)7041 for the existing PWK process.)

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

  • 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).
  • 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, TN 37202, or
    Send via esMD
  • 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.

Serial Claim Impacted HCPCS Listing – Medical Review List

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