When a beneficiary transitions from a non-contract supplier to a contract supplier, does a new order need to be obtained by the contract supplier?
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 or from a contract supplier to a contract supplier, this constitutes a change in suppliers and a new detailed written order is required.
Under competitive bidding, most transitions from non-contract suppliers to contract suppliers will occur during the first few months of the contract period. In order to facilitate these transitions for new competitive bidding contract suppliers and avoid disruptions in service for beneficiaries during the first few months of the contract period, the contract supplier is only required to obtain a new dispensing order from the treating physician prior to providing a competitively bid item. The contract supplier does not need to acquire a detailed written order before submitting a claim for a competitively bid item furnished prior to November 1, 2013, but must obtain the detailed written order prior to November 1, 2013. For changes in suppliers that occur on or after November 1, 2013, the new contract supplier does need to acquire a detailed written order before submitting a claim for a competitively bid item.
In addition, for changes in suppliers that occur before November 1, 2013, a new dispensing order must be obtained before submitting a claim for a competitively bid item if the contract supplier is not able to obtain or validate the original order and other required documents from the non-contract supplier. If documentation in the beneficiary’s medical record as of the date of the transition is obtained from the non-contract supplier and that documentation meets Medicare requirements for documenting medical necessity, the contract supplier does not have to obtain a new written order until November 1, 2013. Copies of documents, rather than original documents, are acceptable during the transition period prior to November 1, 2013. For the Round 2 and national mail-order competitions, this policy applies to changes in suppliers for competitively bid items from a non-contract supplier to a contract supplier in which the transition to the new supplier and initial date of service for the new equipment takes place from July 1, 2013, through October 31, 2013.
Note: 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 produce 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.