Eligibility Options Available via the Jurisdiction A DME MAC IVR

The DME MAC A Call Center has seen an increase of calls due to eligibility denials
for a Medicare beneficiary.  Some of the common ANSI denials associated with eligibility
include, but aren’t limited to:

* ANSI 22: Payment adjusted because this care may be covered by another payer per
coordination of benefits.
* ANSI 13: The date of death precedes the date of service.
* ANSI 24: Payment for charges adjusted.  Charges are covered under a capitation
 agreement/managed care plan.
* ANSI B15 with remark code N70: This service/procedure requires that a qualifying
service/procedure be received and covered.  The qualifying other service/procedure
has not been received/adjudicated.  Consolidated billing and payment applies.
* ANSI 45 with remark code N88: Charge exceeds fee schedule/maximum allowable or
 contracted/legislated fee arrangement.  This payment is being made conditionally.
 A Home Heath Agency episode of care notice has been filed for this patient.  When
a patient is treated under a HHA episode of care, consolidated billing requires
that certain therapy services and supplies, such as this, be included in the HHA’s
payment. This payment will need to be recouped from you if we establish that the
 patient is concurrently receiving treatment under a HHA episode of care.
* ANSI B9: Patient is enrolled in a Hospice
* ANSI 109 with remark code M2: Claim not covered by this payer/contractor. You
must send the claim to the correct payer/contractor. Not paid separately when the
patient is an inpatient.
* ANSI 109 with remark code MA101: Claim not covered by this payer/contractor. You
must send the claim to the correct payer/contractor. A Skilled Nursing Facility
(SNF) is responsible for payment of outside providers who furnish these services/supplies
to residents.

Note:The ANSI denials listed above typically have a CO (contractual obligation)
or PR (patient responsibility) reported with the code.

The Centers for Medicare & Medicaid Services (CMS) requires suppliers to utilize
 self-service options, such as the interactive voice response (IVR) system.  When
calling the DME MAC A Call Center and asking for eligibility and/or explanation
of a denial, you will be directed back to the IVR.

The IVR, 866-419-9458, is available for the supplier community Monday -Friday, 6:00
a.m. – 7:00 p.m. EST and Saturday, 6:00 a.m. – 3:00 p.m. EST

In order to obtain eligibility through the IVR, suppliers will need to select option
2.  After selecting option 2, the IVR will request and collect the following elements:

* PTAN (ten-digit supplier number)
* Last five digits of the Tax Identification Number (TIN)
* Beneficiary Medicare number
* Beneficiary first and last name (last name and first initial if using touch-tone)
* Beneficiary date of birth
* Date of service

Once the authentication elements have been verified, the IVR will supply the following

* Part A and Part B effective/termination dates
* Current/prior year Part B deductible amounts
* Medicare secondary payer (MSP) type, insurer name, and effective/termination dates
* Medicare advantage plan number, name, address, telephone number, and effective/termination
* Home health name, address, and effective/termination dates
* Hospice name, address, and effective/termination dates
* Date of death
* Corrected Medicare number

Effective January 14, 2011, a new enhancement was added to the Claims option (option
1) on the IVR.  Suppliers are able to select Claim Details (touch tone 4) in order
to obtain admission/discharge dates and patient status date if the claim denied
due to Home Health, Hospice, Inpatient Stay, or Skilled Nursing Facility.  Suppliers
will also be able to obtain the name and address of the facility.