CMS Pub. 100-04, ch. 37, § 1.1.2

Prosthetics Orthotics and Supplies (DMEPOS) Claims

(Rev. 11427; Issued: 05-20-22; Effective: 01-01-23; Implementation: 01-03-23)

NOTE: CMS seeks to reduce burden and modernize processes to ensure a reduction in

improper payments and an increase in customer satisfaction. The Certificate of Medical

Necessity (CMN) form and DME Information Form (DIF) were originally required to

help document the medical necessity and other coverage criteria for selected Durable

Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) items. In the past, a

supplier received a signed CMN from the treating physician or created and signed a DIF

to submit with the claim. Due to improvements in claims processing and medical records

management, the information found on CMNs or DIFs is available either on the claim or

in the medical record and is redundant. Therefore, to reduce burden and increase

customer satisfaction, providers and suppliers no longer need to submit these forms for

services rendered after January 1, 2023.

• For claims with dates of service on or after January 1, 2023 – providers and

suppliers no longer need to submit CMNs or DIFs with claims. Due to electronic

filing requirements, claims received with these forms attached will be rejected

and returned to the provider or supplier.

• For claims with dates of service prior to January 1, 2023 – processes will not

change and if the CMN or DIF is required, it will still need to be submitted with

the claim, or be on file with a previous claim.

This statement applies throughout the Program Integrity Manual wherever CMNs and

DIFs are mentioned.

The process of receiving VA DMEPOS claims for a no-pay Electronic Medicare

Remittance Advice (e-MRA) is effective on April 1, 2018. The processing of these

claims, as with the Part A and Part B claims, allows for a CMS no-pay e-MRA to be

generated for all DMEPOS claims submitted to CMS by the VA. VA DMEPOS claims

are processed by a single DME MAC. For VA DMEPOS claims the e-MRA displays the

amount that Medicare would have paid for the claim using the same fee schedule

payments as DMEPOS Medicare claims would’ve paid and are based on the beneficiary’s

state of residence. The same deductible and coinsurance rules applicable to Medicare are

applied to the VA claims and are provided on the e-MRA.

The VA submits DMEPOS claims via the ANSI X12 837P electronic format. The VA

claims will be processed through the Medicare DME MAC Common Electronic Data

Interchange (CEDI) front end system, DMEPOS claims processing system (VMS) and

the common working file (CWF). In addition to following the ANSI X12 837P

standards for claims submissions the following criteria applies:

• The VA's submitter of record is the approved biller and submits all VA electronic

claims to CEDI.

• The VA supplies CMS, the VA DME MAC and CEDI with the VA facility NPI

list. Validation of the NPI is done at the CMS front end contractor.

• VA claims are processed as mandatory assigned claims, no beneficiary submitted

claims will be processed.

• VA DMEPOS submitted claims must be for beneficiaries that reside in the US

and its territories.

• The VA must submit claims for Medicare approved HCPCS provided on the

DMEPOS jurisdiction list which can be found at

https://www.cms.gov/Center/Provider-Type/Durable-Medical-Equipment-DME-

Center.html.

• The VA DMEPOS claims are subject to the Medicare timely filing rules. Claims

will be accepted for processing with dates of service one year prior to the date of

receipt.

• The VA will submit paper CMNs for DMEPOS items that require a CMN per

Medicare rules. The CMNs will be faxed (until the time VA has the ability to

submit CMNs electronically) to the DME MAC. Claims requiring a CMN may be

held for up to 2 weeks to allow for receipt of the CMN. Claims will be denied if a

CMN is not received within 2 weeks.

The CWF edits to ensure the same three conditions stated above for A/B claims are

applicable and must be present for adjudication on the DMEPOS claims. In addition,

MSP claims are accepted from the VA and the CWF will apply MSP editing to VA

DMEPOS claims.

Finalized claims will be included in the VA e-MRA and produced in the CMS flat file

format. CEDI will translate the VA e-MRA flat file to the ANSI X12 835 format and

make the file(s) available for the VA’s submitter of record to retrieve.

Adjustments to claims submitted by the VA can be made only for redeterminations or

cancels. This applies to all DMEPOS claims submitted by the VA for VA facilities and

for independent suppliers.