Produced by - Mead Johnson Nutrition

e-opening to the entity that last reviewed the claim (e.g.,DMERC, hearing officer, ALJ). If a re-opening of a claimis denied, no further action is available to the claimant.HANDLING OVER- OR UNDER-PAYMENTMedicare allows an enteral provider to billprospectively for one month only. However, retrospectivebilling is simpler and more likely to assure correct andaccurate claims.Billing retrospectively can present problems forproviders. Because most providers deal with nursinghomes or other caregivers, they are dependent upon othersfor accurate, timely information. It is not uncommon forclaims to be submitted to Medicare by the provider only tolearn later that the patient’s order was changed or therapywas discontinued. When this happens, under- or overbillingmay occur. When a claim is under- or over-billed,the provider is expected to notify the DMERC of thebilling error.Over-PaymentThe following are the procedures for handling anover-payment:❏A cover letter should be sent to the appropriateDMERC stating that over-payment hasoccurred; the cover letter should include thefollowing information:➝ The beneficiary’s name➝ The HIC number➝ The date the service was over-billed❏❏❏Enclose a copy of the Explanation of MedicalBenefits (EOMB) with the over-billed amountcircled; the number of correct units should bewritten on the EOMBThe DMERC will send a letter to notify theprovider of the dollar amount that needs to berefundedThe supplier will send the DMERC a refundcheck within 30 days or the DMERC will offsetthe amount over-paid on the next check it issuesto the supplierUnder-PaymentThe following are the procedures for handling anunder-payment:❏The supplier must submit the claim through thereview process❏ Attachments to the claim should include:➝ A copy of the EOMB with the mistakescircled➝ Copies of the original and corrected HCFA-1500 forms➝ Copies of the original and corrected CMNformsThe following Exhibits 13 and 14 show the generallyaccepted indications for enteral therapy with ICD-9-CMcodes and the clinical conditions for swallowing disorderswith ICD-9-CM codes respectively.May, 2002 61