The DME MAC Jurisdiction A prepayment review of claims for CPAP Devices (HCPCS E0601) found a claim denial rate of 52% for claims with dates of service primarily from January 2011 through June 2011.
This review was initiated due to errors identified by the Comprehensive Error Rate Testing (CERT) Contractor. This review involved prepayment complex medical review of 828 claims submitted by 369 suppliers. Responses to the Additional Documentation Request (ADR) were not received for 123 (15%) of the claims. Of the 705 claims for which responses were received, 337 claims were allowed and 368 were denied. This resulted in a claim denial rate of 52%. The total denied allowance amount (dollar amount of allowable charges for services determined to be billed in error) divided by the total allowance amount of services medically reviewed resulted in an overall Charge Denial Rate of 48.9%.
Based on the review of the documentation received, the primary reasons for denial were face to face clinical evaluation documentation issues, detailed written order issues, sleep study documentation issues, proof of delivery documentation issues, training documentation issue, and other miscellaneous issues.