When I received the topic for this newsletter from the ladies at Essentially Women I knew that there was only one way to answer their questions. TOOTSIE POPS yes TOOTSIE POPS . “How many licks to get to the tootsie roll center of a tootsie pop” Remember the commercial where the Owl would take the kids lollipop and count “one, two, three CRUNCH” That commercial came out in 1970 and the world has been mystified ever since.
As an adventuring youth I set out to solve this several times. Perhaps I had a little more free time than others, but there were several occasions that myself and a chosen friend would decide to pick a rainy day, two lollipops and set our minds to getting past “CRUNCH” I am happy to announce that it takes exactly ****** to get to the center. Come on!!!! You didn’t think I was really going to disclose that information did you?!?! That’s top secret.
Perhaps that is the how you feel about the rules regarding submission of claims for certain products that your fine organizations support. Bras, prosthesis, mastectomy products and the organizations that you submit them to are not TOP SECRET but it does take some focused effort on getting the appropriate answers. I can see it now, “Mr Owl how many times can you submit a breast prosthesis in one year to CMS?” the owl responds “one, two CRUNCH” The crunch is him throwing the Medicare manual at the wall.
So I am going to build you a cheat sheet so you don’t have to go through a rainy day and a bunch of lollipops and of course the CRUNCH. I have combined the appropriate websites that have all the information you will need for proper claims submission.
It should be noted that effective, March 1, 2008, the Local Coverage Determinations will revert back to the DME MACs and the policy information will be required to be located on each jurisdiction's website.
DME MAC A - National Heritage Insurance Company (NHIC) - www.medicarenhic.com
Program Safeguard Contractor - Tricenturion
http://www.tricenturion.com/content/lcd_current_dyn.cfm
DME MAC B - National Government Services (NGS) - www.adminastar.com
Program Safeguard Contractor - Tricenturion
http://www.tricenturion.com/content/lcd_current_dyn.cfm
DME MAC C - Cigna Government Services - www.cignagovernmentservices.com/jc/
Program Safeguard Contractor - Trust Solutions
http://www.cms.hhs.gov/mcd/viewlcd.asp?lcd_id=11554&lcd_version=16&show=all
DME MAC D - Noridian Administrative Services - www.noridianmedicare.com
Program Safeguard Contractor - EDS/IntegriGuard
http://www.cms.hhs.gov/mcd/viewlcd.asp?lcd_id=11569&lcd_version=15&show=all
The DME Classification System website which provides fee schedules for all states
http://www3.palmettogba.com/dmecs/do/search
And finally the answer to the question how many times can you submit a claim for a breast prothesis?
The useful lifetime expectancy for silicone breast prostheses is 2 years. For fabric, foam, or fiber filled breast prostheses, the useful lifetime expectancy is 6 months. Replacement sooner than the useful lifetime because of ordinary wear and tear will be denied as noncovered.
An external breast prosthesis of the same type can be replaced at any time if it is lost or is irreparably damaged (this does not include ordinary wear and tear). An external breast prosthesis of a different type can be covered at any time if there is a change in the patient's medical condition necessitating a different type of item.
The Medicare program will pay for only one breast prosthesis per side for the useful lifetime of the prosthesis. Two prostheses, one per side, are allowed for those persons who have had bilateral mastectomies. More than one external breast prosthesis per side will be denied as not medically necessary.
For the purpose of medical policy, bras are considered breast prostheses. Most are made of fabric, foam or fiber and fall into the 6-month utilization. Breast forms are typically manufactured from silicone and have a longer useful lifetime expectancy of 2 years.
There you are. All the information you need to submit your claims with confidence. I am hopeful that this will save you valuable time researching this information and give you more time for the important things you need to run your business. Like taking care of your customers, and of course the ultimate question: “How many licks does it take to get to the tootsie roll center of a tootsie pop?”
When you find the answer be sure to send me an email with your answer. I will combine them, average them out we will write a letter to Tootsie Pop with our findings.
Be well talk soon.
Douglas Stallbaumer
HMS is a full service billing solution. If you would like to submit questions about issues that you are dealing with and woud like answered in the next issue please forward them to dstallbaumer@hmsbillingservice.com or call 866-662-1442.