CMC Medicare & Medicaid Funding 4

Question 1

A Medicare claim for a power wheelchair is denied at the initial determination level. The beneficiary has how many days from receipt of the denial notice to file a redetermination request?

Accepted Answer

60 days

Answer

Medicare beneficiaries have 120 calendar days from receipt of the initial determination to file a redetermination, but the standard filing window is 120 days; however, the first level 'redetermination' must be filed within 120 days — note that Part B DME redeterminations must be filed within 120 days.

Question 2

A supplier submits a prior authorization request for a Group 3 power wheelchair. CMS's Prior Authorization Program for CRT requires that the request include:

Accepted Answer

A detailed written order, supporting clinical documentation, and the ATP's evaluation

Answer

CMS requires a detailed written order, complete clinical documentation supporting medical necessity, and the Assistive Technology Professional's evaluation for Group 3 CRT prior authorization.

Question 3

Under Medicare's five-level appeals process, which level involves an Administrative Law Judge (ALJ) hearing?

Accepted Answer

Level 3 — ALJ Hearing

Answer

Level 3 of the Medicare appeals process is an ALJ hearing before the Office of Medicare Hearings and Appeals, available when the disputed amount meets the minimum threshold.

Question 4

A claim is denied because the beneficiary's diagnosis code does not support medical necessity for a power wheelchair. The MOST effective corrective action is:

Accepted Answer

Obtain additional clinical documentation linking the diagnosis to functional limitations

Answer

Obtaining additional clinical documentation that clearly links the diagnosis to the specific functional limitations justifying a power wheelchair is the appropriate corrective action for a medical necessity denial.

Question 5

Which entity conducts Level 2 Medicare appeals (reconsideration) for DME claims?

Accepted Answer

A Qualified Independent Contractor (QIC)

Answer

Level 2 reconsiderations for Medicare DME claims are conducted by a Qualified Independent Contractor (QIC) that is separate from the contractor that made the initial determination.

(CMC) Certified Mobility Consultant Practice Test

(CMC) Certified Mobility Consultant Practice Test

CMC Medicare & Medicaid Funding 4