Different DME MAC Billing

The local Medicare carrier processing physicians’ claims are based on where the provider is located and the Medicare Contractor having jurisdiction over that area. However, the DME contractor to adjudicate the claim is based on the patient’s legal address. Your patient’s legal address is confirmed by the DME Contractor which is obtained from the Common Work File (CWF). This information is maintained by the Social Security Administration. The CWF also contains other patient demographics such as the patient’s legal name, address, gender, etc.

The first step is to be sure that the patient is still on Fee For Service Medicare and not an Advantage Plan. Based on your question, this does not seem to be the issue, but double checking to be sure of this is nevertheless a good idea, especially if other medical/surgical claims are being denied.

If the patient still is on Fee For Service Medicare and if the claim was submitted electronically, to the Common Electronic Data Interchange (CEDI), then the CEDI should theoretically have sent you an electronic message that the claim is being forward to the correct DME MAC.

This Front-End Advisory alerts you to the fact that the patient's legal address is something different then what you assumed. If you did receive this message, then no action on your part is necessary and the correct DME MAC should be processing the claim shortly.

If the claim was submitted by paper or you received no Front-End Advisory from CEDI, then there is a good likelihood that you received or will receive an outright rejection for this claim, which will not be appealable. The EOB should contain the information on which DME MAC the claim will need to be submitted to.

You do not need to enroll separately with the DME MAC for this specific patient because when you enrolled as a DMEPOS provider you are entitled to submit claims to all four DME MAC. You then have two choices, submit the claim to the correct DME MAC by paper or electronically. If you choose to submit the claim electronically and directly to the DME MAC and bypassing the CEDI, you will need to enroll as an electronic filer with that DME MAC.

For the future, ask your patients if they winter/summer somewhere other than near your  office and ask if that winter/summer location is their legal address. If so, DME claims should be directed to that appropriate DME MAC.

If the patient tells you that their local address is their legal address and the rejection is wrong, the patient (or their power of attorney) must contact the Social Security Administration to correct any errors within the CWF.