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Medicare MedRx: CGM Refill Too Soon Response
Scheduled Maintenance
Report for Optum Solutions
Completed
The scheduled maintenance has been completed.
In progress
Scheduled maintenance is currently in progress. We will provide updates as necessary.
Scheduled
This message is intended for Medicare MedRx customers billing CGMs.
In January 2024, CMS published guidelines to begin allowing 3 units of service of the CGM supply allowance for a 90-day supply. Because CGM supply allowance codes are adjudicated with no grace period, it is essential that providers bill according to the guidelines.
Optum currently follows those guidelines in allowing providers to bill up to 90-day supply. In auditing our product, we made changes in how our “Refill Too Soon” calculations to ensure they are aligned with the actual adjudication outcomes for CGM supply allowance codes.
Examples:
Transmission 1 DOS Jan 1 = 28 days’ supply in transaction quantity of 1. While you may dispense sensors to a patient, you cannot bill another supply allowance until 30 days are exhausted.
Below is a link to CMS provided examples of how to bill sensors that may come as 14/15 day supplies.
Glucose Monitors - JD DME - Noridian
A4239 - Supply allowance for non-adjunctive, non-implanted continuous glucose monitor (CGM), includes all supplies and accessories
-1 month supply = 1 unit of service (days supply values 1-30)
-2 month supply = 2 units of service (days supply values 31-60)
-3 month supply = 3 units of service (day supply values 61-90)
From CMS:
Continuous Glucose Monitor (CGM) Supply Allowance
If a DME supplier wants to provide CGM items prior to the expected end of the current supply, they are welcome to do so, but they must not bill the Medicare program until the 30 or 90 days has passed, depending on when the items were billed last. When a DME supplier provides either a 30-day or 90-day supply, a claim narrative indicating the number of supplies is not required. The presence of 1 unit of service will indicate a 30-day supply and 3 units of service will indicate a 90-day supply.
In January 2024, CMS published guidelines to begin allowing 3 units of service of the CGM supply allowance for a 90-day supply. Because CGM supply allowance codes are adjudicated with no grace period, it is essential that providers bill according to the guidelines.
Optum currently follows those guidelines in allowing providers to bill up to 90-day supply. In auditing our product, we made changes in how our “Refill Too Soon” calculations to ensure they are aligned with the actual adjudication outcomes for CGM supply allowance codes.
Examples:
Transmission 1 DOS Jan 1 = 28 days’ supply in transaction quantity of 1. While you may dispense sensors to a patient, you cannot bill another supply allowance until 30 days are exhausted.
Below is a link to CMS provided examples of how to bill sensors that may come as 14/15 day supplies.
Glucose Monitors - JD DME - Noridian
A4239 - Supply allowance for non-adjunctive, non-implanted continuous glucose monitor (CGM), includes all supplies and accessories
-1 month supply = 1 unit of service (days supply values 1-30)
-2 month supply = 2 units of service (days supply values 31-60)
-3 month supply = 3 units of service (day supply values 61-90)
From CMS:
Continuous Glucose Monitor (CGM) Supply Allowance
If a DME supplier wants to provide CGM items prior to the expected end of the current supply, they are welcome to do so, but they must not bill the Medicare program until the 30 or 90 days has passed, depending on when the items were billed last. When a DME supplier provides either a 30-day or 90-day supply, a claim narrative indicating the number of supplies is not required. The presence of 1 unit of service will indicate a 30-day supply and 3 units of service will indicate a 90-day supply.
This scheduled maintenance affected: Pharmacy Solutions (MedRx).