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Performant Recovery posted one new complex issue to their approved issues list.

Blood Glucose Test or Reagent Strips (A4353)

On June 14, 2019, Performant Recovery, the National DMEPOS RAC, added blood glucose test or regeant strips (A4353) to their approved issues list. Performant will review claims for blood glucose test strips for claims that have a ‘claim paid date’ which is less than 3 years prior to the Additional Documentation Request. The quantity of glucose test strips that are covered depends upon the usual medical needs of the diabetic patient.

Documentation will be reviewed to determine if the utilization guidelines for blood glucose test strips were met.

Want some help? Come to the experts! 

The van Halem Group offers proactive and reactive services to assist you. If you receive an audit request from the RAC our clinical team will review the claim file and respond to the audit on your behalf. If denied, we will work with you to obtain addendums and appeal the overpayment.

Want to feel confident that the equipment you are providing meets coverage criteria? Sign up for our clinical prescreen review program.

Before you put out the equipment, let our clinical staff review your documentation to ensure the equipment meets coverage criteria. Our clinicians will review your documentation and provide you with an “approved” or “denied” status, along with recommendations for your referral source. Get your documentation right before you bill the claim to Medicare, and rest easy knowing you are protected should those claims be audited in the future.  In fact, we feel so confident in our clinical prescreen process, if you receive a denial on a claim that received vHG “approval”, we will appeal on your behalf – for free*! That is how confident we are in our  prescreen program.

*Claim must be submitted with same documentation provided at prescreen level. Any changes or alterations void free appeal.

Contact us for more information!

Applicable Policy References:

1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1862(a)(1)(A) - Exclusions from Coverage and Medicare as a Secondary Payer
2. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e) - Payment of Benefits
3. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1834 - Special Payment Rules
4. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1834(j) - Requirements for Suppliers of Medical Equipment and Supplies
5. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1842(p)(4)- Provisions Relating to the Administration of Part B
6. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1861(s) - Medical and Other Health Services Definitions
7. 42 CFR §405.980- Reopening of Initial Determinations, Redeterminations, Reconsiderations, Decisions, and Reviews, (b)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Initiated by a Contractor; and (c)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Requested by a Party
8. 42 CFR §405.986- Good Cause for Reopening
9. 42 CFR §424.57- Special payment rules for items furnished by DMEPOS suppliers and issuance of DMEPOS supplier billing privileges
10. 42 CFR §424.57(c)- Application Certification Standards
11. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §3.2.3.8- No Response or Insufficient Response to Additional Documentation Requests
12. Medicare Program Integrity Manual, Chapter 4- Program Integrity, §4.26 Supplier Proof of Delivery Documentation Requirements Medicare Benefit Policy Manual, Chapter 15- Covered Medical and Other Health Services, §110- Durable Medical Equipment- General
13. Medicare Program Integrity Manual, Chapter 5, Section 5.2 - Rules Concerning Orders, Physician Orders
14. Medicare Program Integrity Manual, Chapter 5, Section 5.2.1- Rules Concerning Orders, Physician Orders
15. Medicare Program Integrity Manual, Chapter 5, Section 5.2.2 – Verbal and Preliminary Written Orders
16. Medicare Program Integrity Manual, Chapter 5, Section 5.2.3- Rules Concerning Orders, Detailed Written Orders
17. Medicare Program Integrity Manual, Chapter 5, Section 5.2.7 - Requirements of New Orders
18. Medicare Program Integrity Manual, Chapter 5, Section 5.2.8 - Refills of DMEPOS Items Provided on a Recurring Basis
19. Medicare Program Integrity Manual, Chapter 5, Section 5.7- Documentation in the Patient’s Medical Record
20. Medicare Program Integrity Manual, Chapter 5, Section 5.8- Supplier Documentation
21. Medicare Program Integrity Manual, Chapter 5, Section 5.9- Evidence of Medical Necessity
22. CMS Pub. 100-03, (Medicare National Coverage Determinations Manual), Chapter 1 Coverage Determinations, Section 40.2 Home Blood Glucose Monitors
23. CMS Pub. 100-03, (Medicare National Coverage Determinations Manual), Chapter 1 Coverage Determinations, Section 190.20- Blood Glucose Testing
24. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Determination L33822-Glucose Monitors, Effective Date: 10/1/2015; Revised 01/12/2017
25. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Article A52464 Glucose Monitor - Policy Article, Effective Date: 10/01/2015; Revised: 06/07/2018
26. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Article: Standard Documentation Requirements for All Claims Submitted to DME MACs A55426 - Effective 01/01/2017; Revised 08/28/2018