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Educational Review Request

ERR Update

As we prepare to transition the Jurisdiction B DME MAC contract to CGS, 4/1/2016 will be the last day to submit your documentation to the ERR Project Team for review. The ERR Project will no longer be accepting new submissions after 4/1/2016; however, the ERR Team will continue to process submissions until all ERRs are completed.

Project Overview

The ERR project is a voluntary, educational opportunity for suppliers to have documentation reviewed by a clinician, prior to claim submission. The ERR project is focused on these medical policies: hospital beds and accessories, Group 2 pressure reducing support surfaces, PAP devices for the treatment of obstructive sleep apnea, therapeutic shoes for persons with diabetes and manual wheelchair bases for standard manual wheelchairs (K0001).

The ERR project allows a clinician to review the documentation a supplier has  submitted and determine if the documentation supports the coverage criteria outlined in the LCDs and PAs. The main objective is to offer suppliers an opportunity to receive personalized support with educational letters explaining the proficiencies and deficiencies of their documentation, and ultimately improving their ability to meet documentation requirements for future audits from the DME MACs and other contracted entities.

Note: This project is for educational purposes and is not considered a prior approval program for durable medical equipment items and does not guarantee payment for these services.

How Do I Participate?

Prior to submitting your claim, you may provide us with your documentation that supports the medical necessity and payment requirements either prior to delivery, or following delivery of the durable medical equipment item(s). You will have two opportunities to submit documentation for the same HCPCS for a specific beneficiary.

Note: For PAP device reviews, you will have two opportunities to submit documentation for the initial coverage, and two opportunities for the continued coverage beyond the first three months of therapy.

An ERR that is submitted prior to your item(s) being delivered must include the following:

  1.  Completed coversheet
  2. Order (please see the policy for specific order requirements)
  3. Face-to-face examination (if applicable)
  4. Medical documentation that supports medical necessity

An ERR that is submitted following delivery of your item(s) must include the following:

  1. Completed coversheet
  2. Order (please see the policy for specific order requirements)
  3. Face-to-face examination (if applicable)
  4. Medical documentation that supports medical necessity
  5. Proof of delivery
    • Note: If an order is not included in the submission, the ERR will not be completed.

If you have other relevant medical documentation you would like to provide to us, you may submit it with your request. Once you’ve obtained all the documentation needed for an ERR, you may submit it by using one of the methods below:

Fax

315-442-4053 (preferred method)

Mail

National Government Services, Inc.
Attn: POE- Educational Review Request
P.O. Box 7149
Indianapolis, IN 46207-7149

NGSConnex

http://www.NGSConnex.com

Instructions on how to submit an ERR for a Group 2 support surfaces, hospital beds, therapeutic shoes or PAP devices using NGSConnex can be found in the Quick Steps Job Aid on the NGSConnex home page.

Note: When utilizing NGSConnex for documentation submissions, you will be unable to submit documentation for review of standard manual wheelchair (K0001) requirements. Documentation pertaining to this HCPCS will only be accepted via fax or mail.

How Soon Will I Receive Results?

If you submit your documentation for review prior to your item(s) being delivered, the request will be expedited for a clinician to review. After review, the clinician will contact you as soon as possible regarding the results via telephone, followed by a written response. 

If you submit your documentation for review following delivery of your item(s), a clinician will review the documentation within 20 business days and a written response will be sent with the results.

What Happens After I Receive My Results?

An ERR that has documentation which supports the medical necessity and payment requirements outlined in the LCD and PA, will receive a supported decision.

If you receive a supported decision, you may:

  • contact us directly with any further comments or questions at 317-841-4459; or
  • proceed with submitting your claim.

An ERR that does not have documentation which supports the medical necessity and payment requirements outlined in the LCD and PA, will receive a nonsupported decision.

If you receive a nonsupported decision, you may:

  • contact us directly with any further comments or questions at 317-841-4459; or
  • submit your documentation for a final review after the documentation has been corrected; or
  • proceed with submitting your claim after the documentation has been corrected.

By taking advantage of this personalized educational experience, we will assist you in improving the quality and accuracy of your documentation. In addition, this education will help you prepare your documentation for future audits and potentially reduce the need to appeal.

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