July 9th, 2015
(Issued: 06-08-12, Effective: 01-01-11, Implementation: 06-19-12) B3-3116, B-3102
Claims for DMEPOS submitted by suppliers for durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) are handled by Durable Medical Equipment Medicare Administrative Contractors (DME MACs).
To determine which services are processed by DME MACs vs. local carriers, CMS maintains and updates a table of services by HCPCS code that indicates who to bill for which services. The CMS updates this list by a special One-Time Special Notification as needed. In general, claims for DMEPOS, other than implanted durable medical equipment and implanted prosthetic devices, are processed by the appropriate DME MAC. The appropriate A/B MAC processes claims for implanted durable medical equipment and implanted prosthetic devices, as well as DMEPOS items incident to a physician’s service.
Note that surgical procedures for implantable DME or for prosthetic devices, performed in an inpatient or outpatient hospital setting include the cost of the device in the Diagnosis Related Group (DRG) or Ambulatory Payment Classification (APC) rate. However, there are some implantable devices that are eligible for separate pass through under Outpatient Prospective Payment System (OPPS). DME MACs do not process claims for DMEPOS items that are subject to consolidated billing or bundled payment under Prospective Payment System (PPS) or in a DRG.
Claims from parenteral and enteral nutrition (PEN) suppliers are processed by the DME MAC.
Method II ESRD claims for dates of service prior to January 1, 2011, are also processed by the DME MAC. For dates of service on and after January 1, 2011, refer to Section 30.3.8 for information regarding the elimination of Method II home dialysis.
The claims processing jurisdiction among DME MACs is determined by the beneficiary’s permanent address. A beneficiary’s permanent address is determined by where the beneficiary resides for more than six months of a year. See the CMS Web site at http://www.cms.hhs.gov/contacts/incardir.asp for a list of State jurisdictions by DME MAC.