NGS Announces Notification of Prepayment Review
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National Government Services (Jurisdiction B DME MAC) Announces Notification of Prepayment Review for Therapeutic Shoes
 
The National Government Services Jurisdiction B Durable Medical Equipment Medicare Administrative Contractor (DME MAC) Medical Review Department will be initiating a prepayment medical review of claims for therapeutic shoes.  Suppliers of the selected claims will be sent a documentation request letter in the mail for the information listed below.  The requested documentation must be returned no later than 30 days from the date of the letter, or the claim will be denied as not medically necessary.
  • Copy of a valid physician's order prior to the date of service on the claim
  • A detailed description of the items to be dispensed
  • The treating physician's signature
  • If the signature is illegible, a signature key that includes the typed name of the physician with credentials, the physician's signature, and the physician's initials is required
  • The date of the signature
  • The start date of the order (only required if the start date is different than the signature date)
  • Copy of the Statement of Certifying Physician prior to the date of service on the claim
  • Documentation from the certifying physician's medical records prior to the date of service on the claim showing that the patient has one or more of the following conditions:
1. Previous amputation of the other foot, or part of either foot, or
2. History of previous foot ulceration of either foot, or
3. History of pre-ulcerative calluses of either foot, or
4. Peripheral neuropathy with evidence of callus formation of either foot, or
5. Foot deformity of either foot, or
6. Poor circulation in either foot
  • Documentation from the certifying physician's current medical records prior to the date of service on the claim that validates that the patient is under a comprehensive plan of care for his/her diabetes
  • Manufacturer and product name/number of the shoes and the inserts that were provided
  • For inserts billed with Healthcare Common Procedure Coding System (HCPCS) code A5513 that are not listed on the Durable Medical Equipment Coding System (DMECS) productClassification List, a description of the process and materials that are used to custom fabricate the inserts
  • Valid proof of delivery—including the patient's name, item delivered, and date of delivery
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