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Claim Documentation

Documentation Requirements for All Claims

Medicare requires you to have proper documentation to support payment of your claim. While Medicare does not require documentation to be submitted with every claim, it must be kept on file and be available upon request. Before submitting a claim to the DME MAC, you must have on file a Standard Written Order, the Certificate of Medical Necessity (CMN) (if applicable), the DME MAC Information Form (DIF) (if applicable), information from the treating physician concerning the patient's diagnosis, and any information required for the use of specific modifiers of attestation statements as defined in certain Local Coverage Determinations (LCDs). Refer to: Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)External Website

We have created a variety of checklists to assist with documentation for specific items, and they are linked below. An Additional Documentation Request letter will be sent if documentation is requested for review.

Documentation to Submit with an Initial Claim

There may be specific circumstances that require submission of documentation with the claim when the claim is submitted to Medicare. Medicare does not encourage submission of unsolicited documentation unless specifically required.

  • Certificate of Medical Necessity (CMN) or DME Information Form (DIF) – A CMN or DIF is required on specific items when required in the Local Coverage Determination.

    CMS is discontinuing the use of CMNs and DIFs for dates of service on or after January 1, 2023. For services on or after January 1, 2023, Common Electronic Data Interchange (CEDI) will reject electronic claims submitted with a CMN or DIF.

    For dates of service prior to January 1, 2023, the following forms should be obtained:
      • CMS-484 – Oxygen
      • CMS-846 – Pneumatic Compression Devices
      • CMS-847 – Osteogenesis Stimulators
      • CMS-848 – Transcutaneous Electrical Nerve Stimulators
      • CMS-849 – Seat Lift Mechanisms
      • CMS-854 – Section C Continuation Form
      • CMS-10125 – External Infusion Pumps
      • CMS-10126 – Enteral and Parenteral Nutrition
    • Paper Claim: Submit a copy of the completed CMN or DIF with the paper claim.
    • Electronic Claims: Enter the information from the CMN or DIF in the appropriate electronic fields. Note: A copy of the completed CMN or DIF must be kept on file and made available upon request.
    Refer to the Joint DME MAC Publication CMS Issues Interim Final Rules with Comment (CMS-1744-IFC & CMS-5531-IFC) – COVID-19 Public Health Emergency for information on use of the CMN for oxygen and DIF for external infusion pumps during the COVID-19 Public Health Emergency (PHE).
  • 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.

    Suppliers should note that if an initial serial claim is denied after a medical review due to the DME MAC's additional documentation request (ADR), 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. The process used to submit additional documentation will depend on how the claim is submitted:
    • Paper claim: Any additional documentation must be attached to the claim form.
    • Electronic claim: The existing PWK process must be followed and the claim must also include the word "serial" in the NTE02 segment.
    Items/supplies that are not included on the Serial Claims Master HCPCS List may still be reviewed following normal processes. The serial claims processes will be used in conjunction with existing CGS Medical Review processes.

How to Submit Documentation with an Initial Electronic Claim

When submitting an electronic claim, there may be times when additional documentation is needed in order for the claim to be properly adjudicated. If the information can be sent using the claim narrative (NTE segment), we encourage you to use the NTE segment. In instances when the NTE or narrative segment is insufficient, the PWK Segment is a function within the 837 Professional and Institutional electronic transactions which allows for an electronic submission of additional claim documentation via mail, fax or esMD. Refer to the PWK Segment page for more information.

When Documentation is Requested

Documentation may be requested by DME MAC Medical Review and various other contractors such as: Comprehensive Error Rate Testing (CERT), Supplemental Medical Review Contractor (SMRC), Recovery Auditor Contractor (RAC), and the Unified Program Integrity Contractor (UPIC) after a claim is submitted.  The letter will include detailed information about what documentation is being requested, who is requesting it, where to send it, how it may be sent, and the date it must be received by. Refer to Additional Documentation Request for information about letters requesting documentation after the claim has been submitted.

Related Information:

Revised: 11.27.23


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