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:
- Before filing a claim, contact the beneficiary to make sure you have his/her current address.
- Ask the beneficiary if he/she has more than one address (i.e., snow birds). If the beneficiary does have more than one, ask which one is currently on file with Medicare/Social Security.
- When filing the claim, be sure to list the correct and current beneficiary address on the claim. If the address on the claim does not match the address in Medicare's records, the claim may be denied.
- File your claim promptly. If you wait several months to file the claim, the beneficiary may have moved since the item/service was rendered, and you may no longer have his/her current address.
- If you know that the beneficiary has recently moved, ask him/her to be sure that Medicare/Social Security has been informed of the address change.