Q1. What HCPCS are eligible for ADMC?
A. Manual wheelchairs
• E1161, K0005, and K0009
• E1231-E1234
Power wheelchairs
• Group 2 (K0835-K0843)
• Group 3 (K0856-K0864)
• Group 4 (K0877-K0886)
• Group 5 (K0890, K0891)
• Group 3 (K0848-K0855) provided with an alternative drive control interface (E2321-E2322, E2325, E2327-E2330)
• Group 4 (K0868-K0871) provided with an alternative drive control interface (E2321-E2322, E2325, E2327-E2330)
New HCPCS within the Power Mobility Device LCD L21271 are in effect for ADMC submissions received on or after 11/15/06. All ADMC requests providing the old HCPCS will be rejected.
Q2. Do I have to provide documentation supporting the need for each item or accessory requested?
A. Any item/accessory requested must have information from the medical record supporting the medical need for that item.
Q3. What is the required demographic information on the first page of the ADMC request?
A. Beneficiary information:
• Name,
• HICN,
• Address
• date of birth,
• Place of Service (can be home, name of facility or POS# submitted on claim)
• ICD-9 diagnosis code (narrative description is not sufficient)
Supplier information: name,
• NSC number,
• Address
• Phone number.
Physician information:
• UPIN (NPI),
• Address and
• Phone number.
Refer to the 20060707 Advance Determination of Medicare Coverage-Wheelchair Bulletin located on TriCenturion's website for complete information. If any of the required information is not provided or is incorrect, the ADMC request will be rejected.
Q4. If I provide the HCPCS code for the wheelchair base being requested, what information must be included to verify the correct HCPCS code is being used?
A. The full model name/number/description or specific identifier to verify the HCPCS code provided is correct must be provided. If complete information is not provided, the ADMC request will be rejected.
Q5. What do you see as the most frequent reason for a wheelchair ADMC denial?
A. For manual wheelchairs, the most common denial reasons are,
• there is no detailed written order listing the specific wheelchair base and each option/accessory
• the HCPCS code associated with each item is not provided
• this order is not signed by the physician
For power wheelchairs, the most common denial reasons are,
• no detailed product description listing the specific wheelchair base and each option/accessory
• the HCPCS code associated with each item is not provided.
• this document is not signed by the physician.
Q6. If my ADMC request is rejected, can I submit another request?
A. Yes. An ADMC may be resubmitted when the corrections are completed according to the initial response letter.
Q7. If my ADMC request was approved but I forgot an accessory, can I send in another request to have the accessory added to the original request?
A. No. This is viewed as a duplicate request and will be rejected. Simply add the new accessory to your claim submission and be prepared to provide the medical record information to support medical necessity, if requested.
Q8. By providing the physician's face to face evaluation date on the physician's order and documentation from a licensed/certified medical provider of medical necessity, do I need to include the face to face examination report?
A. Yes. If the physician's face to face examination report is not provided, the ADMC request will be denied.
Q9. If my ADMC request is denied, can I send in another ADMC request with additional information within the six month period?
A. If an ADMC request is denied a supplier may resubmit it once during the following 6 months. The supplier cannot submit an APPEAL of the ADMC denial through the usual appeals process – i.e., as a redetermination request.
Q10. After submitting an ADMC request, how do I know it has been received?
A. If you fax your ADMC request, you should receive confirmation from your fax machine. If you send your request by certified mail, you will receive a confirmation from the postal service.
Q11. How long should I wait after sending in a request to submit another?
A. Within 30 calendar days of receipt of the ADMC request, a determination will be made and a letter sent to the requestor. Resubmitting a request slows down the process of rendering a determination and will be rejected as a duplicate.
Q12. Whom do I contact if I have a question about the status of my ADMC request or the determination of the request?
A. For all questions regarding ADMC, including status/receipt questions, call the respective Regions Customer Service Department. Any questions submitted to TriCenturion via telephone, fax or letter will be re-directed to the appropriate Customer Service Department.
Jurisdiction A NHIC
Suppliers call 1-866-419-9458
Beneficiaries call 1-800-633-4227
TTY 1-888-897-7539
Jurisdiction B-Adminastar Federal
Suppliers call 1-877-299-7900
Beneficiaries call 1-800-633-4227
TTY 1-317-841-4677
Q13. How can I keep up with all the changes required for ADMC requests?
A. To receive the most up to date information, go to www.tricenturion.com and click on the link to sign up for TriCenturion's listserv. Listserv subscribers receive e-mail notification of all changes as they are posted and there is no cost involved.