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CGS Administrators, LLC

Serving the states of MN, WI, IL, IN, OH, KY and MI

June 19, 2017

21st Century CURES Act Mass Adjustments – What You Need to Know!

MLN Matters MM9968 - Extension of the Transition to the Fully Adjusted Durable Medical Equipment, Prosthetics, Orthotics and Supplies Payment Rates under Section 16007 of the 21st Century Cures Act was published in CGS News on May 9, 2017. This article provides guidelines for DME MACs to reprocess non-competitive bid claims affected by the 21st Century Cures Act for dates of service July 1, 2016, through December 31, 2016. In mid-May, per authorization from CMS, CGS conducted a Beta test and sent a batch of these claims through for adjustment. CGS will begin the full mass adjustment process in accordance with CMS instruction. Most adjustments will result in a higher payment. These mass adjustments will continue until they are completed, which will be approximately 24 weeks. A certain volume of claims will be released and adjusted each day. We expect the vast majority of claim adjustments will be processed to completion without any manual adjudication.

Suppliers should review their remittance advices for adjusted claims. CMS has authorized that DME MACs can add remittance code N689 to the remittance notice for these claims. The message associated with N689 is "Alert: This reversal is due to a retroactive rate change." N689 will be in the 2100.MOA segment of the Electronic Remittance Advice and in the claim header MIA/MOA section on the printed remittance statement, known as the Standard Paper Remittance.

Please be aware, these CURES Act adjusted claims will be processed against all online and common working file edits such as inpatient stays in a skilled nursing facility, Medicare advantage plan enrollment, and home health episodes and could deny based on these edits. You will receive an overpayment demand letter for these claims. It is also important to note that if there is a crossover agreement in place for adjusted claims; CGS will forward these claims to the appropriate health insurance carrier.

There is no need for suppliers to call the Provider Contact Center to see if their claims have been adjusted or when their claims will be adjusted as we expect the mass adjustment process to take approximately 24 weeks to complete. CGS will notify suppliers once the mass adjustment process is complete via ListServ announcements as well as postings on our social media accounts Facebook and Twitter.

Once the mass adjustment process is complete in approximately 24 weeks, suppliers should submit a request to reopen the claim if it should have been processed with the KE modifier. CGS recommends that requests to append the KE modifier be faxed to Written Reopenings at 615.660.5978 for Jurisdiction B. Use the Reopening Request template located on our website under "Forms." You may submit a spreadsheet if there are multiple claims involved, but you must include the following information:

Please do not include more than 250 claims per Reopening request.

CGS will keep you updated on the overall adjustment process and will schedule some follow-up webinars focusing on MM9968. These will take place in July and August, with the likelihood of more to come throughout the fall. Watch the Jurisdiction ListServs for these webinars to be announced.

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