Produced by - Mead Johnson Nutrition

RECERTIFICATION SCHEDULESWith initial claims for enteral nutrition formulas,pumps, and IV poles, a certificate of medical necessitymust be submitted to the DMERC. Section B of the CMNfor enteral nutrition may be completed by someone otherthan the ordering physician. However, the CMN must bereviewed for the accuracy, signed, and dated by theordering physician to indicate agreement. The CMN forenteral nutrition is DMERC 10.Regularly scheduled recertifications are no longernecessary with the effective date of this policy. However,recertifications may be requested on an individual basis atthe discretion of the DMERC. The effective date of thispolicy is based on claims received on or after July 1, 1996.A new initial certification would be required when aformula billed with a different code which has not beenpreviously certified is ordered, or when enteral nutritionservices are resumed after they have not been required fortwo consecutive months.UTILIZATION PARAMETERSThe feeding supply kit (B4034-B4036) mustcorrespond to the method of administration. If a pumpsupply kit is ordered and the medical necessity of thepump is not documented, payment will be based on theallowance for the least costly alternative.AppealFirst AppealSecond AppealThird AppealFourth AppealFifth AppealEXHIBIT 12MEDICAL APPEALS PROCESSMedical Appeals ProcessInformal ReviewFair HearingAdministrative Law Judge(ALJ) HearingDepartmental Appeals Board (DAB)Judicial ReviewA review or hearing may be requested by any of theseparties:❏ A beneficiary or patient who received the service❏ A representative chosen by the beneficiary❏❏A participating supplier (i.e., a supplier whoalways takes assignment on services performedfor Medicare beneficiaries)A non-participating supplier taking assignmentfor a specific serviceHANDLING ENTERAL PRESCRIPTION CHANGESA revised CMN is required when there is a change inan enteral prescription. The revised CMN will show theeffective date of the change. Examples of reasons for arevised CMN include:❏ A change in the physician’s orders in thecategory of nutrients (different code) and/orcalories prescribed❏ A change in the number of days per week theformula is administered❏ A change in the route of administration (i.e.,from NG to G tube)❏ Enteral nutrition services are resumed after theyhave not been required❏ A change in a category IV or V formula beingprovided; the initial date listed in section A of arevised CMN for code B4154 or B4155 mustmatch the initial date on the certification recordfor code B4154 or B4155 set up by DMERCPrescribing physicians are required to sign anddate the completed CMN. Suppliers are not allowed tocomplete the form. Fines and penalties can result if asupplier completes section B.HANDLING DENIALSIf a Medicare claim is denied or only partial paymentis made, the claimant may appeal via the MedicareAppeals Process. Requirements are subject to change,so this guide should not be a substitute for checking thecurrent requirements applicable to your claim.First Appeal: Informal ReviewMay, 2002 59❏❏❏❏❏❏The process for the first appeal informal reviewincludes:Evaluation of a previously processed claim bysomeone who was not the original processorThe appeal must be requested by the supplier orbeneficiary and the reason for the appeal mustbe givenThe appeal can be requested up to six monthsafter the original claim denial, but an extensionis available for a good cause such as:➝➝A mental or physical impairment beyondthe filer’s controlAdditional time required to securesupporting documentationReview can be requested by:➝ A letter from the supplier or beneficiary➝ The submission of HCFA form 1964➝ A DMERC-produced formSupporting documentation for internal review:➝ A detailed letter from the patient’sphysician that includes patient anddiagnosis specific information➝ Laboratory reports➝ Nursing home records➝ Physicians’ records