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No. A CHOW is a business transaction between two DMEPOS suppliers; CMS is not a party to that transaction. However, CMS is a party to any novation agreement involving a competitive bidding contract. CMS will execute a novation following a CHOW only if the successor or new entity meets all program requirements identified in §414.422(d). For more information, please see the CHOW fact sheet by selecting a round from the left hand navigation pane, then selecting Fact Sheets under Educational Information.
Yes. When CMS signs the novation agreement, it will become effective retroactive to the effective date of the CHOW.
Please wait to submit claims for contract items you furnish after the CHOW until CMS notifies you that the novation agreement has been accepted.
If you submit claims before the novation agreement has been accepted, the Durable Medical Equipment Medicare Administrative Contractors (DME MACs) will not know that you are a contract supplier, and the claims may be denied.
Payment for covered items furnished after the effective date of the CHOW will be made at the single payment amount according to the competitive bidding contract.
For more information, please see the CHOW fact sheet by selecting a round from the left hand navigation pane, then selecting Fact Sheets under Educational Information.
New accessories or supplies, such as the CPAP mask in the example given, would not be necessary just because of the transition to the new supplier. The normal utilization parameters continue to apply unless the accessory previously purchased from the non-contract supplier does not work with the new equipment furnished by the contract supplier. If a previously purchased accessory is not compatible with the new equipment, the contract supplier may bill for the new item(s). Due to claims editing limitations, the new item(s) may deny for “same or similar” and require a redetermination. Resolution through the appeals channel is the proper process to follow. Changing base equipment that renders the accessories unusable due to incompatibility is a justifiable reason to replace the accessory.
Note: Most supplies used with PAP devices are dispensed in three-month amounts. With the exception of humidifiers and certain filters, these supplies are regarded as interchangeable between devices. Thus, the supplies obtained in December should be sufficient to meet the beneficiary’s needs until the next quarter, at which time the new supplier may provide and bill for a three-month supply.
The Grandfathering for Rented DME fact sheet indicates that the current supplier and the new contract supplier must coordinate the pickup and delivery of the equipment so that service to the beneficiary is not disrupted. The current supplier should provide copies of all supporting documentation, such as the physician order or Certificate of Medical Necessity (CMN) when applicable, to the new contract supplier. The CPAP compliance data would be an example of supporting documentation. The contract supplier needs to obtain all documents and information necessary to demonstrate adherence to coverage requirements set forth in statute, regulation, rule, or national or local coverage determinations.
For more information, please view the Grandfathering for Rented DME fact sheet, by selecting a round from the left hand navigation pane, then selecting Fact Sheets under Educational Information.
Medicare program integrity guidelines require a new order when there is a change in suppliers. When a beneficiary transitions from a non-contract supplier to a contract supplier, this constitutes a change in suppliers and a new detailed written order is required.
The coverage criteria for an item are unaffected by the competitive bidding status of a supplier. Each supplier that bills for an item must, in the event of an audit, be able to provide sufficient information to show that the reimbursement criteria are met. Suppliers may share information among themselves. If required information is not available, it may be necessary to repeat testing, required trials, physician visits, etc., in order to be able to justify payment. Medicare claims payment history does not provide the type of information necessary to demonstrate that coverage criteria have been met.
No, assuming the patient met the coverage requirements during the initial 90-day trial.
The non-contract supplier must continue to furnish and bill for the rented DME item up to the first “anniversary date” that occurs after the start of the Competitive Bidding Program. (The anniversary date is the day of the month on which the item was first delivered to the beneficiary. Please note that an anniversary date can change if there is a break in service or need of more than 30 days.)
Under no circumstances may the noncontract supplier discontinue services by picking up a medically necessary item prior to the end of a month for which the supplier is eligible to receive a rental payment, even if the last day ends after the start date of the Competitive Bidding Program.
If a beneficiary chooses to switch to a contract supplier, the non-contract supplier and the contract supplier must make arrangements for the pickup of the old equipment and delivery of the new equipment that are suitable to the beneficiary. Such arrangements need to be coordinated between the non-contract and contract suppliers to ensure that the beneficiary has continued access to medically necessary equipment.
The contract supplier can start billing beginning with the first anniversary date that occurs once the Competitive Bidding Program begins.
Under the Competitive Bidding Program, the contract supplier is responsible for maintaining rented equipment. Maintenance and servicing of beneficiary-owned equipment may be performed by any supplier with a valid Medicare billing number. All Medicare-enrolled suppliers, including contract suppliers, must be in compliance with all of the supplier standards and be accredited. The Medicare-enrolled supplier is always responsible for meeting the supplier standards under 42 CFR 424.57, regardless of whether it chooses to make repairs or perform maintenance directly or through a subcontractor.
For more information, please view the Repairs and Replacement fact sheet, which you can find on this website by selecting a round from the left hand navigation pane, then selecting Fact Sheets under Educational Information.