CMS Manual System - CGS Medicare

1 CMS Manual System Department of Health & Human Services (DHHS) Pub 100-04 Medicare Claims processing Centers for Medicare & Medicaid Services (CMS) Transmittal 3444 Date: January 29, 2016 Change Request 9468 SUBJECT: Payment for Purchased Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Furnished to Medicare Beneficiaries Residing Outside the - Expatriate Beneficiaries I. SUMMARY OF CHANGES: In accordance with the Social Security Act, claims for purchased Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) provided to Medicare beneficiaries living outside the are payable as long as the delivery occurred while the beneficiary was in the at the time the service was rendered.

2 However, Medicare claims systems are currently not designated to accept and process claims submitted for DMEPOS furnished to eligible beneficiaries living abroad (expatriate beneficiaries). This transmittal directs the Centers for Medicare & Medicaid Services (CMS) shared systems maintainers to implement claims processing systems changes to allow expatriate beneficiary claims to process and pay for purchased items when certain criteria are met in accordance with Medicare policy. EFFECTIVE DATE: July 1, 2016 *Unless otherwise specified, the effective date is the date of service.

3 IMPLEMENTATION DATE: July 5, 2016 Disclaimer for Manual changes only: The revision date and transmittal number apply only to red italicized material. Any other material was previously published and remains unchanged. However, if this revision contains a table of contents, you will receive the new/revised information only, and not the entire table of contents. II. CHANGES IN Manual INSTRUCTIONS: (N/A if Manual is not updated) R=REVISED, N=NEW, D=DELETED-Only One Per Row. R/N/D CHAPTER / SECTION / SUBSECTION / TITLE N 20 of Expatriate Beneficiary DMEPOS Claims for Purchased Items with the EX Modifier R 24/90/Mandatory Electronic Submission of Medicare Claims III.

4 FUNDING: For Medicare Administrative Contractors (MACs): The Medicare Administrative Contractor is hereby advised that this constitutes technical direction as defined in your contract. CMS does not construe this as a change to the MAC Statement of Work. The contractor is not obligated to incur costs in excess of the amounts allotted in your contract unless and until specifically authorized by the Contracting Officer. If the contractor considers anything provided, as described above, to be outside the current scope of work, the contractor shall withhold performance on the part(s) in question and immediately notify the Contracting Officer, in writing or by e-mail, and request formal directions regarding continued performance requirements.

5 IV. ATTACHMENTS: Business Requirements Manual Instruction Attachment - Business Requirements Pub. 100-04 Transmittal: 3444 Date: January 29, 2016 Change Request: 9468 SUBJECT: Payment for Purchased Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Furnished to Medicare Beneficiaries Residing Outside the - Expatriate Beneficiaries EFFECTIVE DATE: July 1, 2016 *Unless otherwise specified, the effective date is the date of service. IMPLEMENTATION DATE: July 5, 2016 I. GENERAL INFORMATION A.

6 Background: Section 1862(a)(4) of the Social Security Act (the Act) requires that no payment may be made under Part A or Part B for services "which are not provided within the (except for inpatient hospital services furnished outside the under conditions described in section 1814(f) and, subject to such conditions, limitations, and requirements are provided under or pursuant to [title 18 of the Act], physicians' services and ambulance services furnished an individual in conjunction with such inpatient hospital services but only for the period during which such inpatient hospital services were furnished)".

7 Currently, the Medicare claims processing systems are not designed to accept and process claims submitted for DMEPOS furnished to Medicare beneficiaries whose permanent address is abroad (expatriate beneficiaries) even if the DMEPOS is furnished in the The purpose of this transmittal is to require the Centers for Medicare & Medicaid Services (CMS) Medicare shared System maintainers (GDIT, and Acentia), and the Durable Medical Equipment Medicare Administrative Contractors (DME MACs) to allow expatriate beneficiary claims submitted on paper to process and pay when certain criteria are met, according to Medicare policy.

8 B. Policy: Medicare law ( , Section 1862(a)(4) of the Social Security Act (the Act)) prohibits payment for items and services furnished outside the United States except for certain limited services (see section 1814(f) of the Act). The term United States means the 50 States, the District of Columbia, the Commonwealth of Puerto Rico, the United States Virgin Islands, Guam, the Northern Mariana Islands, American Samoa and, for purposes of services rendered on a ship, includes the territorial waters adjoining the land areas of the United States. Currently, Medicare s claims processing systems are not designed to accept and process claims submitted for purchased Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) furnished to a Medicare beneficiary whose address is outside the United States.

9 However, if a purchased DMEPOS item or service is provided to that beneficiary while he or she is in the United States, then that claim is not subject to the payment exclusion at section 1862(a)(4) of the Act and should be processed by Medicare s claims processing systems. The purpose of this CR is to implement the necessary coding changes so that these types of claims are accepted and processed by Medicare . The Supplier will be required to submit paper claims directly to the DME MAC of its jurisdiction. To meet the needs of processing expatriate claims, CMS has instituted the EX modifier to identify the supplier s attestation on the claim that the beneficiary was in the at the time the service was rendered.

10 For beneficiary-submitted claims, submitted using the 1490S form, the beneficiary must also provide the supplier attestation, either in the form of a supplier-written statement or a copy of the supplier 1500 form including the EX modifier. Reimbursement checks should not be sent to countries where payment is barred by Treasury Department regulations as is cited in 31 sec. 3329(a) and 31 CFR sec. Currently, those countries are Cuba and North Korea. II. BUSINESS REQUIREMENTS TABLE "Shall" denotes a mandatory requirement, and "should" denotes an optional requirement.