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CGS Associates, LLC

June 8, 2012

Beneficiary Address—Which Jurisdiction Should Process Your Claim

Recently CGS has seen an increase in claims denied due to a beneficiary's address not being included in Jurisdiction C. When you file a Medicare claim to a DME MAC for durable medical equipment, prosthetics, orthotics, or supplies (DMEPOS), the claim must be processed by the DME MAC whose jurisdiction covers the state where the beneficiary currently resides, even if the beneficiary received the item from a supplier located in a different state. DMEPOS claims are processed based entirely on the beneficiary address, not the location where the item/service was rendered. If a DME MAC receives a claim for a beneficiary whose address is listed as being outside of the DME MAC's jurisdiction (based on Medicare records), the claim will be denied, regardless of the address the supplier lists on the claim for the beneficiary.

If you do receive a denial that states that the claim is "not covered by this payer/contractor," you must resubmit the claim to the correct Medicare contractor. These types of denials typically do not have appeal rights.

Below are some tips to help you avoid receiving denials related to the beneficiary's address:

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