dmerc medicare advisory...march 1994 dmerc medicare advisory page 94-59* texas suppliers were given...

Alabama GeorgiaArkansas KentuckyColorado LouisianaFlorida Mississippi

New Mexico South CarolinaNorth Carolina Tennessee

Oklahoma TexasPuerto Rico Virgin Islands

Palmetto Government Benefits Administrators

Durable Medical Equipment Regional Carrier P.O. Box 100141 Columbia, SC 29202-3141

MARCH 1994 ISSUE 6PAGE 94-57

ATTENTION PHYSICIANS AND SUPPLIERSIN THIS ISSUE:Crossover Problem Identified .................................................... 94-57Notice of Transition Delays ....................................................... 94-58Revised State-By-State Transition Schedule ............................ 94-59Oral Anticancer Drugs .......................................................... 94-60-631994 HCFA Common Procedure Coding System

HCPCS Update ................................................................. 94-63Complementary Insurers ........................................................... 94-63HCFA Common Procedure Coding System (HCPCS)

Coding Help-Line: Commonly Asked Questions .......... 94-64-65HCFA Common Procedure Coding System (HCPCS)

Additions/Changes ....................................................... 94-65-66HCPCS Codes Requiring A CMN ........................................ 94-67-71Prescription Before Delivery ...................................................... 94-71Transition Tips ..................................................................... 94-72-74Electronic Data Interchange (EDI) Help-Line:

Commonly Asked Questions ............................................. 94-75Electronic Data Interchange (EDI) Update ................................ 94-76Advantis Network ...................................................................... 94-76Certified Software Vendors,

Billing Services & Clearinghouses ............................... 94-77-84

Place of Service (POS) ............................................................. 94-85DMEPOS Supplier Specialty Workshops Notice....................... 94-85Supplier Advisory Committee .................................................... 94-85Professional Relations Staff ...................................................... 94-86Ombudsmen Addresses and Their Territories .......................... 94-87Prior Authorization Process ...................................................... 94-88Service Access ......................................................................... 94-89Questions & Answers ................................................................ 94-89Unique Physician Identification Number (UPIN) Directory:

How To Obtain .................................................................. 94-90PEN Supply and Administration Kits ......................................... 94-90Medicare Part B Carrier's Manual:

How To Obtain .................................................................. 94-90Anti-Fraud and Abuse Unit ........................................................ 94-90Using the OCNA Matrix ........................................................ 94-91-951994 Durable Medical Equipment Fee Schedule Corrections ... 94-961994 Pricing Matrix for Virgin Islands and Puerto Rico ...... 94-97-107Telephone Directory ................................................................ 94-108Glossary .................................................................................. 94-109Cumulative Index .................................................................... 94-110

Over 1 Million Claims Received

Over $60

Million Paid in Benefits DMERC MEDICARE ADVISORY

CROSSOVERPROBLEM IDENTIFIED

Resolution In Progress

Palmetto Government Benefits Administrators (Palmetto GBA) recentlybecame aware of a problem interfering with the crossover of paid claims to theappropriate Medicaid agency and to insurers. We have identified the errorand a correction is currently being implemented. The correction will addressboth the claims we have already processed since the inception of transition,as well as all current and future claims. Palmetto GBA will independentlygenerate claim payment information which will be reported to the appropriateMedicaid agencies and the insurers by April 1, 1994.

Also, the correction of this problem will be reflected on remittances noticeswith the notification of crossover by April 1, 1994. We apologize for anyinconvenience this error has caused you.

NOTE: This error does not in any way impact Medigap crossover for partici-pating suppliers.

58 March 1994 DMERC Medicare Advisory

The following is a change to the State-by-State transition schedule for theRegion C Durable Medical Equipment Regional Carrier (DMERC), PalmettoGovernment Benefits Administrators (Palmetto GBA). This change affectsTexas and Florida suppliers only.

The transfer date for Texas suppliers, with the exception of Parenteral andEnteral Nutrition (PEN) suppliers, has been extended to April 1.

Due to the late notice of this decision, and because many suppliers may havealready made systems and other changes, suppliers were given the option totransfer to the DMERC on February 1. Suppliers that began billing the DMERCon February 1, must follow DMERC processing guidelines, (e.g., electronicbilling in the national standard format, using new certificates of medical neces-sity, using new procedure codes, etc.). Suppliers that continue to bill the localcarriers should continue to bill in the same manner as they have in the past.

Because of operational problems at Transamerica, which resulted from theJanuary 17 earthquake, there is no option for Texas PEN suppliers. All TexasPEN suppliers should have transitioned and begun billing Palmetto GBA onFebruary 1.

This adjustment to the transition schedule allows for a smoother overalltransition.

NOTICE OFTRANSITIONDELAYS

Texas Delay

The transfer date for Florida suppliers has been extended to May 1. Due to theshort notice for this change, and because many suppliers may have alreadymade systems and other changes, suppliers in Florida have been given theoption of billing Palmetto GBA on March 1, as scheduled, or continuing to bill theFlorida carrier for DME and the regional specialty carrier (Blue Cross Blue Shieldof South Carolina) for PEN, until May 1. Suppliers that have begun billing theDMERC March 1 must follow DMERC processing guidelines, (e.g., electronicbilling in the national standard format, using new certificates of medical neces-sity, using new procedure codes, etc.). Suppliers that continue to bill the Floridacarrier and the specialty carrier should continue to bill in the same manner as theyhave in the past.

Suppliers not billing Palmetto GBA until May will continue to submit RailroadRetirement Board (RRB) claims to Travelers. This will prevent situations thatrequire suppliers to submit Medicare DMEPOS claims to Florida, and RRBannuitant claims to the appropriate regional carrier, based on beneficiaryresidence.

Suppliers not billing Palmetto GBA until May will continue to submit therapeuticshoe claims to Travelers.

This adjustment to the transition schedule will allow for a smoother overalltransition.

Florida Delay

Railroad RetirementBoard (RRB)Annuitant Claims

March 1994 DMERC Medicare Advisory Page 94-59

* Texas suppliers were given the option to extend their date of transition to April1, 1994 with the exception of PEN suppliers. All Texas PEN suppliers shouldhave transitioned and begun billing to Palmetto GBA on February 1, 1994.

** The transfer date for Florida suppliers has been extended to May 1. Becausemany suppliers may have already made systems and other changes, suppliersin Florida have the option of billing Palmetto GBA on March 1, as scheduled, orcontinuing to bill the Florida carrier for DME and the regional specialty carrier(Blue Cross Blue Shield of South Carolina) for PEN, until May 1.

REVISED STATE-BY-STATE TRANSITIONSCHEDULE

October 1, 1993Early Boarders

November 1, 1993Early Boarders, and

Region A Region B Region C Region DConnecticut Indiana South Carolina MontanaRhode Island Washington

IdahoDecember 1, 1993

Region A Region B Region C Region DMaine Minnesota North Carolina UtahNew Hampshire Ohio Tennessee MissouriVermont West Virginia Kentucky Nebraska

New Mexico KansasOklahoma North DakotaMississippi South Dakota

IowaJanuary 1, 1994

Region A Region B Region C Region DNew Jersey Maryland Louisiana WyomingDelaware Illinois Alabama Alaska

Wisconsin Arkansas OregonDistrict of Columbia ColoradoIncludes the following GeorgiaVirginia Areas:City of AlexandriaArlington CountyFairfax County

February 1, 1994

Region A Region B Region C Region DPennsylvania Michigan Puerto Rico Marianna Islands

Virginia Virgin Islands CaliforniaNevadaHawaiiArizonaGuamAmerican Samoa

March 1, 1994

Region A Region B Region C Region D

April 1, 1994

Region A Region B Region C Region DNew York * Texas

May 1, 1994

Region A Region B Region C Region DMassachusetts ** Florida


ORAL ANTICANCERDRUGS

Effective January 1, 1994, Medicare Part B coverage is extended to include oralanticancer drugs approved by the Food and Drug Administration (FDA). Section13553(a) of the Omnibus Budget Reconciliation Act of 1993 (OBRA 93) providesfor coverage of oral, self-administered, anticancer chemotherapeutic agents.The oral form of the anticancer agent must contain the same active ingredientsused for the same indication as the non-self-administrable form of the drug.Section 13553 (b) provides for greater uniformity in determining coverage of off-labeled uses of FDA-approved drugs and biologicals used in an anticancerchemotherapeutic regimen for a medically accepted indication.

A. Coverage Limitations - For an oral anticancer drug to be covered under PartB, it must:

t be prescribed by a physician or other practitioner licensed to prescribe thedrug as an anticancer chemotherapeutic agent;

t be a FDA-approved drug or biological;

t have the same active ingredients as a non-self-administrable, (e.g., inject-able) drug or biological that would be covered when furnished incident to aphysician's service. To have the same ingredients, the oral drug and the non-self-administrable drug must have the same chemical/generic name asindicated by the FDA's Approved Drug Products (Orange Book), Physician'sDesk Reference (PDR), or an authoritative drug compendium;

t be used for the same indications, including unlabeled uses, as the non-self-administrable version of the drug; and

t be reasonable and necessary for the individual patient.

Currently, the following drugs meet the requirements for coverage underOBRA 93. Use the following National Drug Code (NDC) numbers to billfor these drugs. (Unlike other drugs billable to the DMERC, these oralanticancer drugs are not submitted with HCPCS codes.)

Generic/Chemical Name How Supplied National Drug Code(NDC)

Cyclophosphamide 25 mg/Oral 00015-0504-0150 mg/Oral 00015-0503-01 " 00015-0503-02 " 00015-0503-03

Etoposide 50 mg/Oral 00015-3091-45Methotrexate 2.5 mg/Oral 00536-3998-01

" 00536-3998-36 " 00005-4507-23 " 00555-0572-35 " 00555-0572-02 " 00781-1076-36 " 00781-1076-01 " 00182-1539-01 " 00904-1749-60 " 00378-0014-01 " 58469-3998-30 " 00603-4499-21 " 00364-2499-01 " 51079-0670-05

Melphalan 2 mg/Oral 00081-0045-35


ORAL ANTICANCERDRUGS(Cont'd)

OBRA 93 provides for coverage of off-label (unlabeled) uses of oral antican-cer drugs for medically accepted indications. The off-label uses are coveredif the use of the oral anticancer drug is supported favorably in the AmericanHospital Formulary Service Drug Information, the American Medical Asso-ciation Drug Evaluations, and/or the United States Pharmacopoeia DrugInformation. If unlabeled uses do not appear in these compendia, unlabeleduses may be considered medically accepted if supported by clinical researchin peer reviewed medical literature and journals or determined by the carrierto be generally medically accepted as safe and effective for the particularuse.

Prescription - A physician or other practitioner, (e.g., the physician assistantor nurse practitioner) permitted by license to write prescriptions for legenddrugs must prepare a written order, (i.e., a prescription) or verbal order foran oral anticancer drug. The prescription must be filled by a supplier, (i.e.,pharmacy or dispensing physician or other practitioner) licensed to dispenselegend drugs. Verbal orders must be transcribed and maintained in accor-dance with State pharmacy statutes.

C. Supplier Number - The supplier must have a Medicare supplier billingnumber, which is obtained by writing or calling the National SupplierClearinghouse at:

National Supplier ClearinghouseP.O. Box 100142Columbia, South Carolina 29202-31421-800-851-3682

Suppliers without a valid Medicare supplier billing number may not receiveMedicare payment for their claims. All suppliers with or without a Medicaresupplier billing number must submit claims for oral anticancer drugs onHCFA-1500 (12/90) form.

D. Where to Submit Claims - The residency of the beneficiary determines theregional carrier that processes the claim. Submit claims for oral anticancerdrugs on the HCFA-1500 (12/90) form to the appropriate regional carrier.

Claims for beneficiaries residing in Connecticut, Delaware, Maine, Massa-chusetts, New Hampshire, New Jersey, New York, Pennsylvania, RhodeIsland and Vermont are processed by:

The Travelers Insurance CompanyP.O. Box 6800Wilkes-Barre, PA 18773-68001-800-842-2563

Claims for beneficiaries residing in District of Columbia, Illinois, Indiana,Maryland, Michigan, Minnesota, Ohio, Virginia, West Virginia, and Wiscon-sin are processed by:

Assigned Claims Unassigned ClaimsAdminaStar Federal, Inc. AdminaStar Federal, Inc.P.O. Box 7027 P.O. Box 7031Indianapolis, IN 46207-7078 Indianapolis, IN 46207-70781-800-346-2233 1-800-346-2233



Claims for beneficiaries residing in Alabama, Arkansas, Colorado, Florida,Georgia, Kentucky, Louisiana, Mississippi, New Mexico, North Carolina, Okla-homa, Puerto Rico, South Carolina, Tennessee, Texas and the Virgin Islands areprocessed by:

Palmetto Government Benefits Administrators (Palmetto GBA)Medicare DMERC OperationsP.O. Box 100141Columbia, SC 29202-31411-800-847-4432

NOTE: Please refer to Section 21, Addresses and Telephone Numbers Sectionof the Region C DMEPOS Supplier Manual, for the appropriate Dedi-cated Work Team mailing address for claims submission determined byteam assignment.

Claims for beneficiaries residing in Alaska, Arizona, California, Guam, Hawaii,Idaho, Iowa, Kansas, Missouri, Montana, Nebraska, Nevada, North Dakota,Northern Marianna Islands, Oregon, South Dakota, Utah, Washington, andWyoming are processed by:

Connecticut General Life Insurance Company (CIGNA)P.O. Box 690Nashville, TN 372021-800-488-4184

E. HCFA-1500 (12/90) form - In addition to the patient and insured information,include on the HCFA-1500 (12/90) form the following information:

t Item 17 must contain the name of the physician or other practitioner licensed toprescribe the oral anticancer drug;

t Item 17a must contain the Unique Physician Identification Number (UPIN) forphysicians or the surrogate UPIN "NPP000" for practitioners;

t Item 21 or Item 24E must contain the ICD-9-CM diagnosis code of cancer forwhich the patient is receiving the drug;

t Item 24D must contain the National Drug Code (NDC) number for the oralanticancer drug;

t Item 24F must contain the charge;

t Item 24G must contain the number of units dispensed, each tablet or capsule isequal to one unit.); and

t Item 33 must contain the supplier name and supplier billing number issued by theNational Supplier Clearinghouse.

NOTE: A separate HCFA-1500 (12/90) form must be completed for injectableforms (parenteral route) of anticancer drugs and be submitted to the localcarrier. These claims should not be sent to the DMERCs.

F. Payment - To determine the reasonable charge for oral anticancer drugs, theapproved payment is based on the lower of the actual charge, the averagewholesale prices (AWP) for the generic form of the drug, or in the case of multiplesource drugs, the median of all the generic AWPs or an estimate of actualacquisition costs. In determining the median of the AWP for the generic form of


the drug, the latest editions of such sources as Drug Topics Red Book,American Druggist Blue Book, or Medispan are used. Prices are updatedquarterly.

Payment is subject to Part B deductible and coinsurance. Medicare pays80 percent of the approved drug allowance, subject to the annual Part Bdeductible.

G. Inquiries - If you have any questions regarding Medicare coverage of oralanticancer drugs, contact Palmetto GBA at 1-800-847-4432.


1994 HCFA COMMONPROCEDURE CODINGSYSTEM (HCPCS)UPDATE

Code J9295 was omitted from 1994 HCPCS publication(s). The descriptionstands as follows:

HCPCS DESCRIPTIONJ9295 Polyestradiol Phosphate 40 mg.

Codes J7670 and J7672 were previously billed as "one unit as equal to 1 ml".The code descriptor has changed to "one unit as equal to 2.5 ml". Suppliersshould change their billing procedures for these two codes.

Note that for 1993 dates of service, the days/units field on the claim formshould still reflect one unit as equal to 1 ml. For 1994 dates of service, the days/units field should reflect one unit as equal to 2.5 ml.

MetaproterenolSulfateUnit Changes

Complementary insurers (not to be confused with Medigap) are supplementalinsurers that currently have voluntary written agreements with Medicarecontractors for the routine transfer of Medicare claims information in theMedicare program. The following are the complementary insurers with writtenagreements as of March 8, 1994:

Aetna Life and Casualty InsuranceAmerican Postal Workers UnionBCBS of AlabamaBCBS of South CarolinaBCBS of New Mexico

COMPLEMENTARYINSURERS

Mutual of OmahaNational Association of Letter CarriersOlympic Health


HCFA COMMONPROCEDURE CODINGSYSTEM (HCPCS)CODING HELP-LINE:

The Statistical Analysis Durable Medical Equipment Regional Carrier(SADMERC) operates the HCPCS Coding Help-Line which provides DMEPOScoding assistance to suppliers. The coding advice is developed in conjunctionwith the four DMERCs. The consensus opinion of the DMERCs on any givencoding issue will be given to the suppliers.

NOTE: The HCPCS Coding Help-Line representatives are unable to answercoverage or pricing inquiries.

HCPCS Coding Help-Line: (803) 736-6809Monday through Friday: 9:00 a.m. to 12:00 p.m. and

1:00 p.m. to 4:00 p.m. (Eastern Time)

In January the SADMERC answered 2,661calls. Fifty-five percent of thesecalls were received during the hours of 11:00 to 12:00 and 1:00 to 3:00. If youare having any difficulty reaching a HCPCS Coding Help-Line Representa-tive, you may wish to try your call during other less busy times.

The following questions are the most frequently asked by suppliers whencalling the HCPCS Coding Help-Line.

Q What is the correct code to file for Extra Wide Commode?A E0165

Q What is the correct code to file for Dry Foam Mattress less than 5" peakheight?

A E0199

Q What is the correct code to file for Dry Foam Mattress greater than 5"?A E0184

Q What is the correct code to file for the following exercise/rehabilitationequipment/supplies?

A Stimulation Ball - A9300, Theraputty - A9300, Therabands - A9300, andExercise Pulley - A9300

Q What is the correct code to file for wheel attachments to folding walkers?Skid and Slides (Not Brakes)

A E1399

Q What is the correct code to file for Vacuum Erection System?A K0163

Q What is the correct code to file for a 22" 34" or 36" Wheelchair? (seat only)A K0108

Q What is the correct code to file for an Artificial Larynx?A L8500

Q What is the correct code to file for a “Rib Binder”?A A4572

Q What is the correct code to file for a Custom Rib Binder?A L0220

Q What is the correct code to file for a Removable Molded Shoe Insert?A L3030

Q What is the correct code for Pulmocare?A Level III HCPCS XX049

Commonly AskedQuestions

March 1994 DMERC Medicare Advisory 4-65

Q What is the correct code for Carpel Tunnel Brace?A L3914

Q What is the correct code for diapers, underpads?A A4554

NOTE: The above information is for billing purposes and does not indicate orguarantee coverage of the noted items.

Commonly AskedQuestions(Cont'd)

HCFA COMMONPROCEDURE CODINGSYSTEM (HCPCS)

Additions

The following codes are additions to the 1994 HCPCS listing.

E0669 Segmental pneumatic appliance for use with pneumatic compressor, halfleg

E0670 Segmental pneumatic appliance for use with pneumatic compressor, halfarm

J3535 Drug administered through a metered dose inhalerJ7051 Sterile saline or water, up to 5 ccJ7627 Bitolterol Mesylate, 0.2%, per 10 ml, inhalation solution administered

through DMEL0984 Protective body sock, eachL2275 Addition to lower extremity, varus/vulgus correction, plastic modification,

padded/linedL2397 Addition to lower extremity orthosis, suspension sleeveL5614 Addition to lower extremity, above knee-knee disarticulation, 4-bar linkage,

with pneumatic swing phase controlL5667 Addition to lower extremity, below knee, socket insert, suction suspension,

with locking mechanismL5669 Addition to lower extremity, below knee, socket insert, suction suspension,

without locking mechanismL5700 Replacement, socket, below knee, molded to patient modelL5701 Replacement, socket, above knee/knee disarticulation, including attach-

ment plate, molded to patient modelL5702 Replacement, socket, hip disarticulation, including hip joint, molded to

patient modelL5704 Replacement, custom shaped protective cover, below kneeL5705 Replacement, custom shaped protective cover, above kneeL5706 Replacement, custom shaped protective cover, knee disarticulationL5707 Replacement, custom shaped protective cover, hip disarticulationL5840 Addition, endoskeletal knee/shin system, multiaxial, pneumatic swing

phase controlL5855 Addition, endoskeletal system, hip disarticulation, mechanical hip exten-

sion assistL5925 Addition, endoskeletal system, above knee, knee disarticulation or hip

disarticulation, manualL5962 Addition, endoskeletal system, below knee, flexible protective outer surface

covering systemL5964 Addition, endoskeletal system, above knee, flexible protective outer sur-

face covering systemL5966 Addition, endoskeletal system, hip disarticulation, flexible protective outer

surface covering systemL5979 All lower extremity prostheses, multiaxial ankle/foot, dynamic responseL5981 All lower extremity prostheses, flex-walk system or equalL8485 Stump sock, single ply, fitting, upper limb, eachL8490 Addition to prosthetic sheath/sock, air seal suction retention system

The following are changes to the 1994 HCPCS listing. Deletions in text are markedby strikethrough, additions are marked by brackets [ ].

E0650 Pneumatic compressor, non-segmental home model, (lymphedema pump)E0651 Pneumatic compressor, segmental home model, (lymphedema pump)

without calibrated gradient pressure

Changes


E0652 Pneumatic compressor, segmental home model, (lymphedema pump)with calibrated gradient pressure

E0655 [Non-segmental] pneumatic appliance for use with pneumatic com-pressor, half arm

E0660 [Non-segmental] pneumatic appliance for use with pneumatic com-pressor, full leg

E0665 [Non-segmental] pneumatic appliance for use with pneumatic com-pressor, full arm

E0666 [Non-segmental] pneumatic appliance for use with pneumatic com-pressor, half leg

E0667 [Segmental] pneumatic appliance for use with pneumatic compressor,[full] leg

E0668 [Segmental] pneumatic appliance for use with pneumatic compressor,[full] arm

E0840 Traction frame, attached to headboard, simple cervical tractionE0850 Traction stand, free-standing, simple cervical tractionE0870 Traction frame, attached to footboard, simple extremity traction, (e.g.,

Buck's)E0880 Traction stand, free standing simple extremity traction, (e.g., Buck's)E0890 Traction frame, attached to footboard, simple pelvic tractionE0900 Traction stand, free standing, simple pelvic traction, (e.g., Buck's)J7670 Metaproterenol Sulfate, 0.4%, per [2.5] ml, inhalation solution admin-

istered through DME (Alupent)J7672 Metaproterenol Sulfate, 0.6%, per [2.5] ml, inhalation solution admin-

istered through DME (Alupent, Metaprel)L0390 TLSO, anterior-posterior-lateral control (body jacket), molded to pa-

tient modelL0400 TLSO, anterior-posterior-lateral control (body jacket) molded to patient

model, with interface materialL0410 TLSO, anterior-posterior-lateral control, (body jacket), two-piece con-

struction molded to patient modelL0420 TLSO, anterior-posterior-lateral control, (body jacket), two-piece con-

struction molded to patient model, with interface materialL0430 TLSO, anterior-posterior-lateral control, (body jacket), with interface

material custom fittedL0440 TLSO, anterior-posterior-lateral control, (body jacket),with overlapping

front section, spring steel front, custom fittedL0550 LSO, anterior-posterior-lateral control, (body jacket),molded to patient

modelL0560 LSO, anterior-posterior-lateral control, (body jacket), molded to patient

model, with interface materialL0565 LSO, [anterior-posterior-lateral control, custom fitted]L1844 [KO,] single upright, thigh and calf, with adjustable flexion and exten-

sion joint, medial-lateral and rotation control, custom fitted [molded topatient model]

L2770 Addition to lower extremity orthosis, [any material - per bar or joint]Stainless steel, per bar or joint

L3140 Foot, [rotation positioning device, including shoe(s)] abduction androtation bars, (Dennis Browne type), attached to shoe

L3150 Foot, [rotation positioning device, without shoe(s)] abduction androtation bars, (Dennis Browne type), clamped to shoe

L3908 WHFO, [wrist extension control cock-up, non molded]L4350 Pneumatic ankle control splint, [(e.g., Aircast)] (Aircast or equal)L4360 Pneumatic walking splint, [(e.g., Aircast)] (Aircast or equal)L4370 Pneumatic full leg splint, [(e.g., Aircast)] (Aircast or equal)L4380 Pneumatic knee splint, [(e.g., Aircast)] (Aircast or equal)L5611 Addition to lower extremity, above knee-knee disarticulation, OHC 4

bar linkage, with friction swing phase controlL5613 Addition to lower extremity, above knee-knee disarticulation, OHC 4

bar linkage, with hydraulic swing phase controlL5978 All lower extremity prostheses, foot, multiaxial ankle/foot (Greissinger

or equal)

HCFA COMMONPROCEDURE CODINGSYSTEM (HCPCS)

Changes(Cont'd)

NOTE: The before-mentioned information is for billing purposes anddoes not indicate or guarantee coverage of the noted items.


The following HCPCS codes are the only codes that require a Certificate of Medical Necessity(CMN). The specific CMN required for each code is indicated on this chart. CMNs arerequired per code, not per patient. When electronically submitting claims that require a CMN,the specific CMN record for each code must also be transmitted with that claim to PalmettoGovernment Benefits Administrators. When submitting paper versions of the claims, be sure toinclude each code which requires a CMN, on the CMN. If additional space is required to listthe codes, use the Warranty Section of the CMN to continue your listing.

HCPCS CODESREQUIRING A CMN

A4311 Insertion tray without drainage bag with indwelling catheter, Foley type, two-way latex with coating(teflon, silicone, silicone elastomer or hydrophilic, etc.) 05.01

A4312 Insertion tray without drainage bag with indwelling catheter, Foley type, two-way, all silicone 05.01A4314 Insertion tray with drainage bag with indwelling catheter, Foley type, two-way latex with coating (Teflon, silicone,

silicone elastomer or hydrophilic, etc.) 05.01A4315 Insertion tray with drainage bag with indwelling catheter, Foley type, two-way, all silicone 05.01A4338 Indwelling catheter; Foley type, two-way latex with coating (Teflon, silicone, silicone elastomer, or hydrophilic, etc.) 05.01A4340 Indwelling catheter; specialty type, (e.g., coude, mushroom, wing, etc.) 05.01A4344 Indwelling catheter, Foley type, two-way, all silicone 05.01B4150 Category I, Semi-Synthetic: Intact, Protein/Protein Isolates, (100 calories = 1 unit) 10.01B4151 Enteral Nutrition Formulae, Category 1B, Blenderized: Intact, Protein/Protein, Isolates - Naturalized, (100 calories = 1 unit) 10.01B4152 Enteral Nutrition Formulae, Category II - Intact, Protein/Protein Isolates, (Calorically Dense), (100 calories = 1 unit) 10.01B4153 Enteral Nutrition Formulae, Category III, Hydrolyzed Protein/Amino Acid, (100 calories = 1 unit) 10.01B4154 Enteral Nutrition Formulae, Category IV: defined formula for special metabolic need, (100 calories=1 unit) 10.01B4155 Enteral Nutrition Formulae, Category V: modular components (protein, carbohydrates, fat) 100 calories = 1 unit 10.01B4156 Enteral Nutrition Formulae, Category VI - Standard, (100 calories = 1 unit) 10.01B4164 Parenteral Nutrition Solution, Dextrose, 50% or less (500ML = 1 unit) Home Mix 10.01B4168 Parenteral Nutrition Solution, Amino Acid, 3.5% or less (500 ML = 1 unit) Home Mix 10.01B4172 Parenteral Nutrition Solution, Amino Acid, 5.5% through 7% (500 ML = 1 unit) Home Mix 10.01B4176 Parenteral Nutrition Solution, Amino Acid, 7% through 8.5% (500 ML = 1 unit) Home Mix 10.01B4178 Parenteral Nutrition Solution, Amino Acid, Greater than 8.5% (500 ML = 1 unit) Home Mix 10.01B4180 Parenteral Nutrition Solution, Dextrose, Greater than 50% (500 ML = 1 unit) Home Mix 10.01B4184 Parenteral Nutrition Solution, Lipids, 10% with Administration set (500 ML = 1 unit) 10.01B4186 Parenteral Nutrition Solution, Lipids, 20% with Administration set (500 ML = 1 unit) 10.01B4189 Parenteral Nutrition Solution; Compounded Amino Acid & Carbohydrates with electrolytes, trace elements &

vitamins, including preparation, any strength, 10 to 51 grams of protein - Pre-Mix 10.01B4193 Parenteral Nutrition Solution; Compounded Amino Acid & Carbohydrates with electrolytes, trace elements &



vitamins, including preparation, any strength, over 100 grams of protein - Pre-Mix 10.01B4216 Parenteral Nutrition; Additives (Vitamins, Trace Elements & Electrolytes) Home Mix, per day 10.01B4220 Parenteral nutrition supply kit; premix, per day 10.01B4222 Parenteral nutrition supply kit; home mix, per day 10.01B4224 Parenteral nutrition administration kit, per day 10.01B5000 Parenteral Nutrition Solution; Compounded Amino Acid & Carbohydrates with electrolytes, trace elements &

vitamins, including preparation, any strength, per gram, Renal, Aminosyn RF, Nephramine, Renamine Pre-Mix 10.01B5100 Parenteral Nutrition Solution; Compounded Amino Acid & Carbohydrates with electrolytes, trace elements &

vitamins, including preparation, any strength, per gram, Hepatic, Freamine HBC, Hepatamine - Pre-Mix 10.01B5200 Parenteral Nutrition Solution; Compounded Amino Acid & Carbohydrates with electrolytes, trace elements &

vitamins, including preparation, any strength, per gram, Stress-branch chains amino acids - Pre-Mix 10.01B9000 Enteral Nutrition Pump, no alarm 10.01B9002 Enteral Nutrition Pump, with alarm 10.01B9004 Parenteral Nutrition Pump - Portable 10.01B9006 Parenteral Nutrition Pump - Stationary 10.01E0180 Pressure pad, alternating, with pump 01.01E0181 Pressure pad, alternating, with pump, heavy duty 01.01E0194 Air-fluidized bed 01.01E0250 Hospital bed, fixed height, with any type side rails, with mattress 01.01E0251 Hospital bed, fixed height, with any type side rails, without mattress 01.01E0255 Hospital bed, variable height, hi-lo, with any type side rails, with mattress 01.01E0256 Hospital bed, variable height, hi-lo, with any type side rails, without mattress 01.01E0260 Hospital bed, semi-electric (head and foot adjustment), with any type side rails, with mattress 01.01E0261 Hospital bed, semi-electric (head and foot adjustment), with any type side rails, without mattress 01.01E0265 Hospital bed, total electric, (head, foot and height adjustments), with any type side rails, with mattress 01.01E0266 Hospital bed, total electric (head, foot and height adjustments), with any type side rails, without mattress 01.01E0290 Hospital Bed, fixed height, without side rails, with mattress 01.01E0291 Hospital bed, fixed height, without side rails, without mattress 01.01E0292 Hospital bed, variable height, hi-lo, without side rails, with mattress 01.01E0293 Hospital bed, variable height, hi-lo, without side rails, without mattress 01.01E0294 Hospital bed, semi-electric (head and foot adjustment), without side rails, with mattress 01.01E0295 Hospital bed, semi-electric (head and foot adjustment), without side rails, without mattress 01.01E0296 Hospital bed, total electric (head, foot and height adjustments), without side rails, with mattress 01.01E0297 Hospital bed, total electric (head, foot and height adjustments), without side rails, without mattress 01.01

DMERCHCPCS HCPCS CMNCODE DESCRIPTION REQUIRED



E0424 Stationary compressed gaseous oxygen system, rental; includes contents (per unit), regulator,flow meter, humidifier, nebulizer, cannula or mask, and tubing; one unit = 50 cu. ft. 484

E0431 Portable gaseous oxygen system, rental; includes regulator, flowmeter, humidifier, cannula or mask, and tubing 484E0434 Portable liquid oxygen system, rental; includes portable container, supply reservoir, humidifier, flowmeter, refill adaptor,

contents gauge, cannula or mask, and tubing 484E0439 Stationary liquid oxygen system, rental; includes use of reservoir, contents (per unit), regulator, flowmeter,

humidifier, nebulizer, cannula or mask, and tubing; one unit = 50 lbs. 484E0441 Oxygen contents, gaseous, per unit (for use with owned stationary gaseous stationary systems or when both a

stationary and portable gaseous system are owned; one unit = 50 cu. ft.) 484E0442 Oxygen contents, liquid, per unit (for use with owned liquid stationary systems or when both a stationary and

portable liquid system are owned; one unit = 10 lbs.) 484E0443 Portable oxygen contents, gaseous, per unit (for use only with portable gaseous systems and no

stationary gas or liquid system is used; one unit = 5 cu. ft.) 484E0444 Portable oxygen contents, liquid, per unit (for use only with portable liquid systems when no stationary gas or

liquid system is used; one unit = 1 lb.) 484E0600 Suction pump, home model, portable 484E0601 Continuous airway pressure (CPAP) device 03.01E0607 Home blood glucose monitor 09.01E0609 Blood glucose monitor, with special features, (e.g., voice synthesizers, automatic timers, etc.) 09.01E0627 Seat lift mechanism incorporated into a combination lift-chair mechanism 07.01E0628 Separate seat lift mechanism for use with patient owned furniture - electric 07.01E0629 Separate seat lift mechanism for use with patient owned furniture - non-electric 07.01E0650 Pneumatic compressor, non-segmental home model 04.01E0651 Pneumatic compressor, segmental home model without calibrated gradient pressure 04.01E0652 Pneumatic compressor, segmental home model with calibrated gradient pressure 04.01E0655 Non-segmental pneumatic appliance for use with pneumatic compressor, half arm 04.01E0660 Non-segmental pneumatic appliance for use with pneumatic compressor, full leg 04.01E0665 Non-segmental pneumatic appliance for use with pneumatic compressor, full arm 04.01E0666 Non-segmental pneumatic appliance for use with pneumatic compressor, half leg 04.01E0667 Segmental pneumatic appliance for use with pneumatic compressor, full leg 04.01E0668 Segmental pneumatic appliance for use with pneumatic compressor, full arm 04.01E0720 TENS, two-lead, localized stimulation 06.01E0730 TENS, four-lead, larger area/multiple nerve stimulation 06.01E0731 Form fitting conductive garment for delivery of TENS or NINES (with conductive fibers separated from the patients

skin by layers of fabric) 06.01E0747 Osteogenesis stimulator, non-invasive 04.01E0776RR IV pole 09.01E0781 Ambulatory infusion pump, single or multiple channels, with administrative equipment, worn by patient 09.01E0791 Parenteral Nutrition infusion pump, stationary, single or multi-channel 09.01E1050 Fully-reclining wheelchair, fixed full length arms, swing away detachable elevating leg rests 02.01E1060 Fully-reclining wheelchair, detachable arms, desk or full length, swing away detachable elevating leg rests 02.01E1065 Power attachment (to convert any wheelchair to motorized wheelchair) (e.g., Solo) 02.01E1070 Fully-reclining wheelchair, detachable arms, desk or full length, swing away detachable foot rests 02.01E1083 Hemi-wheelchair, fixed full length arms, swing away detachable elevating leg rests 02.01E1084 Hemi-wheelchair, detachable arms, desk or full length arms, swing away detachable elevating leg rests 02.01E1085 Hemi-wheelchair, fixed full length arms, swing away detachable footrests 02.01E1086 Hemi-wheelchair, detachable arms, desk or full length, swing away detachable foot rests 02.01E1087 High strength lightweight wheelchair, fixed full length arms, swing away detachable elevating leg rests 02.01E1088 High strength lightweight wheelchair, detachable arms, desk or full length, swing away detachable elevating leg rests 02.01E1089 High strength lightweight wheelchair, fixed full length arms, swing away detachable foot rests 02.01E1090 High strength lightweight wheelchair, detachable arms, desk or full length, swing away detachable foot rests 02.01E1091 Youth wheelchair, any type 02.01E1092 Wide heavy duty wheelchair, detachable arms, desk or full length, swing away detachable elevating leg rests 02.01E1093 Wide heavy duty wheelchair, detachable arms, desk or full length, swing away detachable foot rests 02.01E1100 Semi-reclining wheelchair, fixed full length arms, swing away detachable elevating leg rests 02.01E1110 Semi-reclining wheelchair, detachable arms, desk or full length, elevating leg rests 02.01E1130 Standard wheelchair, fixed full length arms, fixed or swing away detachable foot rests 02.01E1140 Wheelchair, detachable arms, desk or full length, swing away detachable foot rests 02.01E1150 Wheelchair, detachable arms, desk or full length, swing away detachable elevating leg rests 02.01E1160 Wheelchair, fixed full length arms, swing away detachable elevating leg rests 02.01E1170 Amputee wheelchair, fixed full length arms, swing away detachable elevating leg rests 02.01E1171 Amputee wheelchair, fixed full length arms, without foot rests or leg rests 02.01E1172 Amputee wheelchair, detachable arms, desk or full length, without foot rests or leg rests 02.01E1180 Amputee wheelchair, detachable arms, desk or full length, swing away detachable foot rests 02.01E1190 Amputee wheelchair, detachable arms, desk or full length, swing away detachable elevating leg rests 02.01E1195 Heavy duty wheelchair, fixed full length arms, swing away detachable elevating leg rests 02.01E1200 Amputee wheelchair, fixed full length arms, swing away detachable foot rests 02.01E1210 Motorized wheelchair, with micro-switch control, fixed full length arms, swing away detachable elevating leg rests 02.01E1211 Motorized wheelchair, with micro-switch control, detachable arms, desk or full length, swing away detachable

elevating legrests 02.01E1212 Motorized wheelchair, with micro-switch control, fixed full length arms, swing away detachable foot rests 02.01E1213 Motorized wheelchair, with micro-switch control, detach-able arms, desk or full length, swing away detachable foot rests 02.01E1220 Wheelchair; specially sized or constructed, (indicate brand name, model number, if any) and justification 02.01

HCPCS Codes Requiring A CMN (Cont'd)



E1221 Special-sized wheelchair with fixed arms, foot rests 02.01E1222 Special-sized wheelchair with fixed arms, elevating leg rests 02.01E1223 Special-sized wheelchair with detachable arms, foot rests 02.01E1224 Special-sized wheelchair with detachable arms, elevating leg rests 02.01E1230 Power operated vehicle (three or four wheel nonhighway) Specify brand name and model number 07.01E1240 Lightweight wheelchair, detachable arms, desk or full length, swing away detachable elevating leg rests 02.01E1250 Lightweight wheelchair, fixed full length arms, swing away detachable foot rests 02.01E1260 Lightweight wheelchair, detachable arms, desk or full length, swing away detachable foot rests 02.01E1270 Lightweight wheelchair, fixed full length arms, swing away detachable elevating leg rests 02.01E1280 Heavy duty wheelchair, detachable arms, desk or full length, elevating leg rests 02.01E1285 Heavy duty wheelchair, fixed full length arms, swing away detachable foot rests 02.01E1290 Heavy duty wheelchair, detachable arms, desk or full length, swing away detachable foot rests 02.01E1295 Heavy duty wheelchair, fixed full length arms, elevating leg rests 02.01E1400 Oxygen concentrator, manufacturer specified maximum flow rate does not exceed 2 liters per minute,

at 85 percent or greater concentration 484E1401 Oxygen concentrator, manufacturer specified maximum flow rate greater than 2 liters per minute, does not

exceed 3 liters per minute, at 85 percent or greater concentration 484E1402 Oxygen concentrator, manufacturer specified maximum flow rate greater than 3 liters per minute,

does not exceed 4 liters per minute, at 85 percent or greater concentration 484E1403 Oxygen concentrator, manufacturer specified maximum flow rate greater than 4 liters per minute,

does not exceed 5 liters per minute, at 85 percent or greater concentration 484E1404 Oxygen concentrator, manufacturer specified maximum flow rate greater than 5 liters per minute,

at 85 percent or greater concentration 484E1405 Oxygen and water vapor enriching system with heated delivery 484E1406 Oxygen and water vapor enriching system without heated delivery 484J2920 Methylprednisolone sodium succinate up to 40 mg. 08.01J2930 Methylprednisolone sodium succinate up to 125 mg. 08.01J7500 Azathioprine, (e.g., Imuran) - oral, tab, 50 mg., 100s ea 08.01J7501 Azathioprine, (e.g., Imuran) - parenteral, vial, 100 mg, 20 ml ea 08.01J7502 Cyclosporine, (e.g., Sandimmune) - oral, sol; 100 mg/ml, 50 ml each 08.01J7503 Cyclosporine, (e.g., Sandimmune) - parenteral, amp, IV, 250 mg, 5 ml. 10S each 08.01J7504 Lymphocyte immune globulin, antitymocyte globulin, (e.g., Atgam) - parenteral, amp, 50 mg/ml, 5 ml each 08.01J7505 Monoclonal antibodies, (e.g., Muromonab CD3; Orthoclone) parenteral, amp, 5 mg/5 ml, 5 ml each 08.01J7506 Prednisone, any dosage, 100 tablets 08.01K0001 Standard wheelchair 02.01K0002 Standard hemi (low seat) wheelchair 02.01K0003 Lightweight wheelchair 02.01K0004 High strength, lightweight wheelchair 02.01K0005 Ultralightweight wheelchair 02.01K0006 Heavy duty wheelchair 02.01K0007 Extra heavy duty wheelchair 02.01K0008 Custom manual wheelchair /base 02.01K0009 Other manual wheelchair/base 02.01K0010 Standard-weight frame motorized/power wheelchair 02.01K0011 Standard-weight frame motorized/power wheelchair with programmable control parameters for

speed adjustment, tremor dampening, acceleration control and braking 02.01K0012 Lightweight portable motorized/power wheelchair 02.01K0013 Custom motorized/power wheelchair base 02.01K0014 Other motorized/power wheelchair base 02.01K0016 Detachable, adjustable height armrest, complete assembly, each 02.01K0017 Detachable, adjustable height armrest, base, each 02.01K0018 Detachable, adjustable height armrest, upper portion each 02.01K0020 Fixed, adjustable height armrest, pair 02.01K0022 Reinforced back upolstery 02.01K0025 Hook-on headrest extension 02.01K0028 Fully reclining back 02.01K0029 Reinforced seat upholstery 02.01K0030 Solid seat insert, planar seat, single density foam 02.01K0031 Safety belt/pelvic strap 02.01K0046 Elevating legrest, lower extension tube, each 02.01K0047 Elevating legrest, upper hanger bracket, each 02.01K0048 Elevating legrest, complete assembly 02.01K0053 Elevating footrests, articulating (telescoping), each 02.01K0101 One-arm drive attachement 02.01K0106 Arm trough, each 02.01K0119 Azathioprine - oral, tab, 50mg 08.01K0120 Azathioprine - parenteral, 100 mg. 08.01K0121 Cyclosporine 0 oral, 25 mg. 08.01K0122 Cyclosporine - parenteral, 250 mg 08.01K0123 Lymphocyte immune globulin, antithmocyte globuline - parenteral, 250 mg 08.01K0124 Monoclonal antibodies - parenteral, 5 mg 08.01K0125 Prednisone - oral, 5mg. 08.01K0148 Hydrogel dressing, each 05.01K0149 Hydrocolloid dressing, each 05.01




K0150 Alginate dressing, each 05.01K0151 Foam dressing, each 05.01K0154 Wound pouch, each 05.01K0166 Methylprednisolone - oral, 4mg. 08.01K0167 Prednisolone - oral, 5 mg. 08.01L1900 Ankle-foot orthosis, (AFO), spring wire, dorsiflexion assist calf band 04.01L1920 AFO, single upright with static or adjustable stop, (Phelps or Perlstein type) 04.01L1930 AFO, custom fitted, plastic 04.01L1940 AFO, molded to patient model, plastic 04.01L1960 AFO, posterior solid ankle, molded to patient model, plastic 04.01L1980 AFO, single upright, free plantar dorsiflexion, solid stirrup, calf band/cuff, (single bar BK orthosis) 04.01L1990 AFO, double upright, free plantar dorsiflexion, solid stirrup, calf band/cuff, (double bar BK orthosis) 04.01L2000 Knee-ankle-foot orthosis, (KAFO), single upright, free knee, free ankle, solid stirrup, thigh and calf bands/cuffs,

(single bar AK orthosis) 04.01L2010 KAFO, single upright, free ankle, solid stirrup, thigh and calf bands/cuffs, (single bar AK orthosis), without knee joint 04.01L2020 KAFO, double upright, free knee, free ankle, solid stirrup, thigh and calf bands/cuffs, (double bar AK orthosis) 04.01L2030 KAFO, double upright, free ankle, solid stirrup, thigh and calf bands/cuffs, (double bar AK orthosis), without knee joint 04.01L2036 KAFO, full plastic, molded to patient model 04.01L2037 KAFO, full plastic, single upright, free-knee, molded to patient model 04.01L2038 KAFO, full plastic, without knee joint, multiaxis ankle, molded to patient model (lively orthosis or equal) 04.01L2102 AFO, fracture orthosis, tibial fracture cast orthosis, plaster type casting material, molded to patient 04.01L2104 AFO, fracture orthosis, tibial fracture cast orthosis, synthetic type casting material, molded to patient 04.01L2106 AFO, fracture orthosis, tibial fracture cast orthosis, thermoplastic type casting material, molded to patient 04.01L2108 AFO, fracture orthosis, tibial fracture cast orthosis, molded to patient model 04.01L2112 AFO, fracture orthosis, tibial fracture orthosis, soft custom fitted 04.01L2114 AFO, fracture orthosis, tibial fracture orthosis, semi-rigid custom fitted 04.01L2116 AFO, fracture orthosis, tibial fracture orthosis, rigid custom fitted 04.01L2122 KAFO, fracture orthosis, femoral fracture cast orthosis, plaster type casting material, molded to patient 04.01L2124 KAFO, fracture orthosis, femoral fracture cast orthosis, synthetic type casting material, molded to patient 04.01L2126 KAFO, fracture orthosis, femoral fracture cast orthosis, thermoplastic type casting material, molded to patient 04.01L2128 KAFO, fracture orthosis, femoral fracture cast orthosis, molded to patient model 04.01L2132 KAFO, fracture orthosis, femoral fracture cast orthosis, soft custom fitted 04.01L2134 KAFO, fracture orthosis, femoral fracture cast orthosis, semi-rigid custom fitted 04.01L2136 KAFO, fracture orthosis, femoral fracture cast orthosis, rigid custom fitted 04.01Q0117 For diabetics only, fitting (including follow-up), custom preparation and supply of off-the-shelf depth-inlay shoe

manufactured to accommodate multi-density insert(s), per shoe 04.01Q0118 For diabetics only, fitting (including follow-up), custom preparation and supply of shoe molded from

cast(s) of patient’s foot (custom molded shoe), per shoe 04.01Q0119 For diabetics only, multiple density insert(s), per shoe 04.01Q0120 For diabetics only, modification (including fitting of off-the-shelf depth-inlay shoe or custom-molded shoe with

roller or rigid rocker bottom, per shoe 04.01Q0121 For diabetics only, modification (including fitting of off-the-shelf depth-inlay shoe or custom-molded shoe with

wedge(s), per shoe 04.01Q0122 For diabetics only, modification (including fitting of off-the-shelf depth-inlay shoe or custom-molded shoe

with metatarsal bar, per shoe 04.01Q0123 For diabetics only, modification (including fitting of off-the-shelf-depth-inlay shoe or custom-molded shoe with

off-set heel(s), per shoe 04.01XX010 Immunosuppressive drug, not otherwise classified 08.01XX030 Category IV Enteral Product, 100 calories = 1 unit, Accupep HPF 10.01XX031 Category IV Enteral Product, 100 calories = 1 unit, Aminaid 10.01XX032 Category IV Enteral Product, 100 calories = 1 unit, Entera opd 10.01XX033 Category IV Enteral Product, 100 calories = 1 unit, Glucerna 10.01XX034 Category IV Enteral Product, 100 calories = 1 unit, Hepatic aid 10.01XX035 Category IV Enteral Product, 100 calories = 1 unit, Impact 10.01XX036 Category IV Enteral Product, 100 calories = 1 unit, Impact with fiber 10.01XX037 Category IV Enteral Product, 100 calories = 1 unit, Imunaid 10.01XX038 Category IV Enteral Product, 100 calories = 1 unit, Lipisorb 10.01XX039 Category IV Enteral Product, 100 calories = 1 unit, Nepro 10.01XX040 Category IV Enteral Product, 100 calories = 1 unit, New Replete 10.01XX041 Category IV Enteral Product, 100 calories = 1 unit, New Replete with Fiber 10.01XX042 Category IV Enteral Product, 100 calories = 1 unit, Nutrihep 10.01XX043 Category IV Enteral Product, 100 calories = 1 unit, Nutrivent 10.01XX044 Category IV Enteral Product, 100 calories = 1 unit, Peptamen 10.01XX045 Category IV Enteral Product, 100 calories = 1 unit, Perative 10.01XX046 Category IV Enteral Product, 100 calories = 1 unit, Pregestimil 10.01XX047 Category IV Enteral Product, 100 calories = 1 unit, Protain XL 10.01XX048 Category IV Enteral Product, 100 calories = 1 unit, Provide 10.01XX049 Category IV Enteral Product, 100 calories = 1 unit, Pulmocare 10.01XX050 Category IV Enteral Product, 100 calories = 1 unit, Reabilan HN 10.01XX051 Category IV Enteral Product, 100 calories = 1 unit, Suplena 10.01XX052 Category IV Enteral Product, 100 calories = 1 unit, Stresstein 10.01XX053 Category IV Enteral Product, 100 calories = 1 unit, Traumacal 10.01XX054 Category IV Enteral Product, 100 calories = 1 unit, Traumaid HBC 10.01XX055 Category IV Enteral Product, 100 calories = 1 unit, Travasorb Hepatic 10.01





XX056 Category IV Enteral Product, 100 calories =1 unit, Travasorb MCT 10.01XX057 Category IV Enteral Product, 100 calories = 1 unit, Travasorb Renal 10.01XX059 Category V Enteral Product, 100 calories = 1 unit, Casec 10.01XX060 Category V Enteral Product, 100 calories = 1 unit, Controlyte 10.01XX061 Category V Enteral Product, 100 calories = 1 unit, Elementra 10.01XX062 Category V Enteral Product, 100 calories = 1 unit, Fibrad 10.01XX063 Category V Enteral Product, 100 calories = 1 unit, Lipomul 10.01XX064 Category V Enteral Product, 100 calories = 1 unit, MCT Oil 10.01XX065 Category V Enteral Product, 100 calories = 1 unit, Microlipid 10.01XX066 Category V Enteral Product, 100 calories = 1 unit, Moducal 10.01XX067 Category V Enteral Product, 100 calories = 1 unit, Nutrisource 10.01XX068 Category V Enteral Product, 100 calories = 1 unit, Polycose 10.01XX069 Category V Enteral Product, 100 calories = 1 unit, Promod 10.01XX070 Category V Enteral Product, 100 calories = 1 unit, Promix 10.01XX071 Category V Enteral Product, 100 calories = 1 unit, Propac 10.01XX072 Category V Enteral Product, 100 calories = 1 unit, Sumacal 10.01

* 1=INEXPENSIVE OR ROUTINELY PURCHASED ITEMS, 2=ITEMS REQUIRING FREQUENT MAINTENANCE, 3=PROSTHETICS ANDORTHOTICS, 4=CAPPED RENTAL ITEMS, 5=OXYGEN AND OXYGEN EQUIPMENT

+ THE MEDICAL POLICIES IN THE DMEPOS SUPPLIER MANUAL WILL BE UPDATED WITH MEDICAL POLICY NUMBERS

* FEE DMERC HCPCS HCPCS + MED SCHED. CMN

CODE DESCRIPTION POLICY CAT. REQUIRED

DECUBITUS CAREA4640 Replacement pad for use with medically necessary alternating pressure pad owned by patient 1E0176 Air pressure pad or cushion, nonpositioning 1E0177 Water pressure pad or cushion, nonpositioning 1E0178 Gel pressure pad or cushion, nonpositioning 1E0179 Dry pressure pad or cushion, nonpositioning, (e.g., eggcrate) 1E0180 Pressure pad, alternating, with pump 1060 4 01.01E0181 Pressure pad, alternating, with pump, heavy duty 1060 4 01.01E0182 Pump for alternating pressure pad 4E0184 Dry pressure mattress 1E0185 Decubitus care pad, flotation or gel pad, with foam leveling pad (mattress size) 1E0186 Air pressure mattress 4E0187 Water pressure mattress 4E0192 Low pressure and positioning equalization pad for wheelchair (for example, roho, jay, etc.) 1E0193 Powered air flotation bed (low air loss therapy) 4E0194 Air-fluidized bed 1070 4 01.01E0196 Gel pressure mattress 4E0197 Air pressure pad for mattress 1E0198 Water pressure pad for mattress 1E0199 Dry pressure pad for mattress, (e.g., eggcrate) 1E0277 Alternating pressure mattress 4

SEAT LIFT MECHANISME0627 Seat lift mechanism incorporated into a combination lift-chair mechanism 2300 1 07.01E0628 Separate seat lift mechanism for use with patient owned furniture - electric 2300 1 07.01E0629 Separate seat lift mechanism for use with patient owned furniture - non-electric 2300 1 07.01

TRANSCUTANEOUS ELECTRIC NERVE STIMULATOR (TENS)E0720 TENS, two-lead, localized stimulation 2200 1 06.01E0730 TENS, four-lead, larger area/multiple nerve stimulation 2200 1 06.01E0731 Form fitting conductive garment for delivery of TENS or NINES (with conductive fibers separated from the

patients skin by layers of fabric) 2200 1 06.01

POWER OPERATED VEHICLE (POV)E1230 Power operated vehicle (three or four wheel nonhighway) Specify brand name and model number 2210 1 07.01

The following HCFA Common Procedure Coding System (HCPCS) codesrequire a prescription before delivery, which must be maintained on file by thesupplier. Prescriptions are not to be sent to the DMERC, unless requested.

PRESCRIPTIONBEFORE DELIVERY


TRANSITION TIPS With a valid National Supplier Clearinghouse-assigned supplier number, eachsupplier receives a Region C DMEPOS Supplier Manual, its revisions, as wellas issues of the DMERC Medicare Advisory. These publications provide allessential claim submission information, therefore, Palmetto GBA stronglyencourages thorough reading of these documents. To obtain a suppliernumber, call the National Supplier Clearinghouse (NSC) at 1-800-851-3682.

To supplement these publications, we thought it would be beneficial to providetransition tips to suppliers on how to avoid possible pitfalls that cause claimprocessing delays, slow payment or periods of nonpayment.

As you submit claims to the DMERC, please consider the following tips:

t Electronically submitted claims should not contain any form of punctuationin the city/state portion of the beneficiary’s address field.

Examples: Ft. Myers should be keyed as Ft MyersColumbia, SC should be keyed as Columbia SC

t Modifiers should only be used when required for the specific HCPCS codesubmitted. For complete instructions on when a modifier is required, pleaseconsult sections 14-20 of the Region C DMEPOS Supplier Manual.

Example: KH, KI, and KJ modifiers are only applicable for capped rentalitems and PEN pumps. For instance, HCPCS L8000 (breast prosthesis,mastectomy bra) is always purchased, therefore, the KH, NU or UEmodifiers would not be submitted with a claim for this code. The only validmodifiers for this code are RT (right) and LT (left).

(For breast prosthesis, modifier information is found in section 17 of theRegion C DMEPOS Supplier Manual.)

t Pricing modifiers should always be the first modifier used in claim submis-sion. Pricing modifiers are RR, NU, UE and MS.

Example: B9002RRBRKJ In this example, RR is the pricing modifier,therefore it appears before the other modifiers.

t When Item 11 on the claim is completed to indicate that there is insuranceprimary to Medicare, the Explanation of Benefits (EOB) from the primaryinsurer must be attached to the claim before the claim can be processed byMedicare as the secondary payer. Claims will be returned if Item 11 hasbeen completed and the EOB is not attached. If Medicare is the primaryinsurer, Item 11 should be completed with “None”.

t In block 24E of the HCFA-1500 (12/90) form, a diagnosis code referencenumber is required. Be sure that the number entered correlates to thediagnosis entered in block 21. Common errors include leaving block 24Eblank when there is actually a diagnosis entered in block 21, keying a 2, 3,or 4 in block 24E when only one diagnosis is entered in block 21 or keyinga “/” in block 24E.

t Claims for capped rental items and Parenteral and Enteral Nutrition (PEN)pumps should not be keyed with span dates of service. This means that the“from” and “to” dates of service should be the same.

Example: 03/01/94-03/31/94 B9002RRKH Incorrect03/01/94-03/01/94 B9002RRKH Correct


TRANSITION TIPS(Cont'd)

t All claims and correspondence submitted to the DMERC should includeyour supplier number as assigned by the National Supplier Clearing-house (NSC). We cannot process claims submitted without a valid NSC-assigned supplier number.

t We ask that you refrain from using highlighter on the paper copies of theHCFA-1500 (12/90) form and the CMNs submitted to the DMERC. Inprocessing, highlighted areas on imaged documents appear black on ourcomputer screen, creating the potential to block out vital claim processinginformation. Specific areas for physician completion may be indicatedwith symbols, i.e., asterisks.

t We are receiving single-sided copies of two-sided documents. Please besure to send both sides of a document if they contain any claimsprocessing information. On the HCFA-1500 (12/90) form, do not writeoutside of the designated blocks, specifically in the upper right-handcorner. We use this area for designation of claim number.

t Please print or use dark type on all correspondence. Cursive is often notlegible.

t Original HCFA-1500 (12/90) forms must be submitted to the DMERC forclaims processing. Photocopies are not acceptable.

t The supplier must keep prescriptions on file. Prescriptions are not to besent to the DMERC, unless requested.

As you begin to submit CMNs to the DMERC, please consider the followingtips:

t In the latest HCFA revision of the grandfathering policy, which is pub-lished in the January 1994 issue of the DMERC Medicare Advisory, itstates that Palmetto GBA must develop for an oxygen certification onoxygen patients certified for less than lifetime. To avoid delays, suppliersshould submit a copy of the current HCFA-484 (1/93) form with the firstoxygen claim filed to the DMERC, for oxygen patients certified for lessthan lifetime.

t ICD-9-CM codes should be used on all claims and coded to the greatestlevel of specificity to accurately describe the patient’s condition. Missingor incomplete diagnosis codes may cause processing delays.

Example: Glucose Monitor supplies are only covered by the regionalcarriers for the diagnosis of diabetes, when the patient is insulin (injection)treated. If you are billing for Glucose Monitor supplies, be sure to indicatebeside the diagnosis code in block 21 of the HCFA-1500 (12/90) form thatthe patient is being treated with insulin. For EMC billers, this informationmay be transmitted in the HA0 record.

t Palmetto Government Benefits Administrators cannot accept PEN claimswith old CMNs. The DMERC CMN 10.01 is the only valid CMN we canaccept for these claims. This includes existing patients who will begrandfathered to the DMERCs. In this situation, the CMN is informationalonly, and “signature on file” may be indicated for the physician’s signa-ture. The signature date on DMERC CMN 10.01 must be the signaturedate of the current CMN on file with the regional PEN carrier. TheGrandfathering policy states: “For Parenteral and Enteral Nutrition (PEN)therapy, the PEN supplier must submit a DMERC CMN for the current


active period of medical necessity with the first claim submitted to theDMERC.” The first claim submitted to the DMERC for a new PEN patientshould include a fully completed DMERC CMN 10.01 which has beenreviewed and signed by the ordering physician. A blank copy of all DMERCCMNs is included in the DMEPOS Supplier Manual for photocopying.

t Clarification: The first PEN certification sent to the DMERC (which is notnecessarily the first certification for the patient) should be marked "Initial."This supersedes all earlier instruction.

t For the initial PEN CMN submitted to the DMERC with the first claim for a PENpatient, Question #6 on the DMERC CMN 10.01 should always be answered“D” for “Does Not Apply.” Answering “N” for “No” causes claim processingdelays because at the time of an initial claim submission there could not havebeen a break in need.

t When submitting the first claim to the DMERC for a new patient, if a CMN isrequired by the DMERC Medical Policy, then that CMN is always consideredto be the initial CMN. A revised or recertification CMN should never besubmitted until there is an initial CMN on file. (Please refer to the January 1994issue of the DMERC Medicare Advisory for specific CMN submissioninformation.)

t For all electronically submitted CMNs (whether or not the patient is beinggrandfathered), you must indicate whether or not you have the paper versionin your files. Be sure to indicate “Y” for yes when the paper version of the CMNis on file. An “N” for no indicates inadequate documentation. We have receivedCMNs with a signature date for a CMN on file, yet “N” appeared on the sameCMN indicating no paper version of the CMN has been obtained.

t We are receiving an inordinate number of paper versions of the CMNs whichwe do not need. This significantly slows claim processing. Most of the CMNswe are receiving are not DMERC CMNs. (Please refer to the January 1994issue of the DMERC Medicare Advisory for specific CMN submission informa-tion.)

t Please use "Y" for Yes, "N" for No, or "D" for Does Not Apply in the spaceprovided on the DMERC CMN question sets (unless otherwise noted). Do notuse check marks, [e.g., (ü), (/), or (x)].

TRANSITION TIPS(Cont'd)


The Palmetto Government Benefits Administrators EDI Help-Line provides suppli-ers with expert assistance with electronic claims filing and other EDI services.

EDI Help-Line: (803) 788-9751

Monday - Friday:7:30 a.m. to 5:00 p.m. (Eastern Time)

Q How many Submitter IDs does one supplier need to submit claims electronicallyto the DMERC?

A Only one Submitter ID is required to send claims to any or all of the fourDMERCs.

Q Must a supplier test for certification with each DMERC?A No. Once a supplier is National Standard Format (NSF) certified with one

DMERC, they are considered to be certified by all DMERCs. However, theymust test for connectivity (the ability to connect with the host computer) witheach DMERC to which they plan to submit claims.

Q How will a supplier know when they are certified?A After successfully submitting a test to Palmetto GBA that includes a minimum

of 20 claims and achieves a 95% or greater claims acceptance rate, the supplierwill be certified for production. They will be able to retrieve error reports and seetheir successful test even before Palmetto GBA notifies them of certification.Within a day of the supplier receiving their successful test, a Palmetto GBA staffmember will update the supplier to production status in our system, then contactthem by telephone to confirm certification and clear them to submit productionclaims. Vendors, Billing Services and Clearinghouses will also receive a writtennotification of certification, which indicates each package for which the com-pany has been certified.

Q If a corporate office wants to bill for several stores, is this possible?A A corporate home office or billing site may bill for any number of satellite stores,

given the home office provides a supplier number for each satellite store andcompletes an Addendum to the Supplier Electronic Media Claims (EMC)Agreement, indicating that the home office accepts contractual responsibility forall claims submitted through the corporate home office.

Q Do suppliers whose claims are submitted through a billing service have to testbefore the billing service can submit their claims?

A No, they do not.

Q Must a supplier have an EMC agreement with Palmetto GBA if they submit mostof their claims to another region and only plan to send a few claims to PalmettoGBA?

A Yes. Palmetto GBA requires the appropriate, signed EMC agreements from anyand all suppliers submitting claims directly to Palmetto GBA.

Q How can a supplier acquire software to begin submitting claims electronically?A Palmetto GBA will provide a Certified Vendor List, which lists all software

vendors, Billing Services and Clearinghouses certified by a DMERC. The listprovides all demographic information about the vendor entity, as well as thosepackages for which the vendor entity has been certified. Palmetto GBA alsooffers a basic, claims data entry/claims submission software package. Contactthe Palmetto GBA EDI Help-Line to request information on acquiring a CertifiedVendor List or Palmetto GBA software.

ELECTRONIC DATAINTERCHANGE (EDI)HELP-LINE:

Commonly AskedQuestions


Approximately half of the DMEPOS claims processed to date have beensubmitted electronically. In February, 1994, over 121,000 electronic claims wereprocessed; 79% of those were done so within 16 days, and 90% within 22 days.These percentages should improve dramatically as start-up glitches with theCWF, HCPC codes, fee schedules, etc. are resolved.

If you are frustrated with leaving messages at our Help Desk (803-788-9751),things should be improved by the time you read this. Over 2,000 calls werelogged in February by the Help Desk for EDI Personnel. We have made aconcerted effort to return phone calls in a timely manner, but we still need yourhelp.

When you call for assistance, be very specific about what your problem is. Thatperson at the Help Desk will dispatch your call based on the information that yougive to him/her. For example, say, “I am in production and do not understand myerror reports,” or “I am trying to test and am getting an [NAK] message.” Yourcalls are logged and prioritized according to what you have told your Help Deskdispatcher.

Calls concerning allowable fees, acceptable HCPC codes, par or non-par statusare questions that should be addressed to your state team or to the NationalSupplier Clearinghouse. Palmetto EDI is responsible for getting your electronicclaims into the system and through our front-end edits. We do not have the claimsprocessing expertise that Provider Services has on the adjudication end.

ELECTRONIC DATAINTERCHANGE(EDI) UPDATE

ADVANTISNETWORK

You’ve heard us talk about it for months! The Advantis Network (formerly HPO/IIN) is now available for EDI transactions with Palmetto GBA.

IBM and the Sears Communications Company have combined decades ofexperience and resources in creating Advantis -- a telecommunications network-- which is now available from three of the four DMERCs (Regions B, C, and D).This network provides easier and faster telecommunications access for yourDMEPOS claims.

Why choose Advantis? Most electronic submitters will be able to use localphone lines to dial into the network, which will automatically forward your files toPalmetto EDI via the fastest and clearest route available. Advantis helps toeliminate those busy phone lines and aborted transmissions which you mayexperience when dialing directly into Palmetto EDI.

Passport is the DOS-based PC communications software link to Advantis.Palmetto EDI is distributing Passport with a customized command file to allsubscribers for $15.00. For added value and service, IBM will be joining PalmettoEDI to provide customer support for installation, connection, transmission ofclaims, and trouble-shooting assistance for Advantis. Screen messages will alsoappear giving you appropriate guidance and phone numbers.

Participating suppliers pay no line or monthly charges. Non-participatingsuppliers contribute a $3.00 per month account charge while enjoying substantialdata transmission discounts - $5.67 per hour! This is as much as 30% less thanthe rate you pay your local phone company.

Be on the lookout for an Advantis “Welcome Packet” and enrollment form in thenear future. Palmetto will continue to anticipate the latest and most efficientmeans of getting your claims processed!


CERTIFIEDSOFTWAREVENDORS, BILLINGSERVICES &CLEARINGHOUSES

The following is a list of certified software vendors, billing services andclearinghouses who have demonstrated their ability and are certified to submitDurable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS)claims and Certificates of Medical Necessity (CMNs) electronically to theDMERCs, as of March 8, 1994. Each company was certified using the DMERCStandard Test Packages.

This is a composite list provided by all four DMERCs. A single list will bepublished by each DMERC and updated bi-weekly throughout the transition,and monthly thereafter. Updated lists may be obtained by contacting yourDMERC, listed below. This information will also be published in each of theDMERC’s newsletters.

Region A: The Travelers CompaniesEMC Technical Support320 S. Pennsylvania Blvd., Suite 339Wilkes-Barre, PA 18701-2215(717) 820-5841

Region B: AdminaStar Electronic ServicesMarketing Department6802 Hillsdale CourtIndianapolis, IN 46250(800) 952-2068

Region C: Palmetto Government Benefits AdministratorsDMERC EDIP.O. Box 100145Columbia, SC 29202-3145(803) 788-9751

Region D: CIGNA MedicareEMC Marketing AssistantsP.O. Box 49Boise, ID 83707(208) 342-4440

The following companies have systems that are certified as fully capable forelectronic submission of all types of DMEPOS claims and certifications, unlessotherwise noted.

Contact Person/Company Name Phone # Limitations

Advanced Solutions Jeff Bane4810 S. 165th St. 402/896-6881Omaha, NE 68135

Bluff Creek Systems Tabitha DarstP.O. Box 1707 903/455-0461Greenville, TX 75403

Breen Systems Jeff DikeBox 507 802/879-4212Willston, VT 05495

DMERC CertifiedSoftware Vendors


DMERC CertifiedSoftware Vendors(Cont'd) Budget Computer Systems Eddie Muniz

10500 N.W. 26th St. 305/477-7770Bldg. 101Miami, FL 33172

Busnet, Inc. Jeff Charnes Certified only9099 Gould Rd. 612/934-3606 for DMERCEden Prairie, MN 55347 CMNs 01.01 and

02.01

CTI George Richman Other Payer11350 Random Hills Rd. 800/456-4284Suite 350Fairfax, VA 22030

California Medical Systems Arnold R. Deleon23101 Lake Center Dr., 714/768-1700Ste. 270El Toro, CA 92630

Capcom David Capell9 Tanner St. West Enter 609/428-0878Haddenfield, NJ 08032

Companion Technologies Frank Harris Other PayerI-20 East @ Alpine Road 803/699-2625Columbia, SC 29219

CompuAims Phoebe Freeman MSP5661 E. Shelby Drive 901/369-8027Memphis, TN 38141

Compusystems Knox Lee Certified only for1 Science Court 803/735-7700 DMERC CMNsColumbia, SC 29203 04.01 & 05.01

Computer Applications Unltd. Scott Straining Other Payer6360 Flank Drive 717/541-0651Suite 100Harrisburg, PA 17112

Computer Support Systems Jim Egan875 Old Roswell Road 404/998-3046Suite G400Roswell, GA 30076

Computers Unlimited Cindy Allen Other Payer2407 Montana Ave. 406/255-9500Billings, MT 59101

Computers Unlimited Mark WhitakerP.O. 1071 503/692-7256Tualitin, OR 97062-1071

Curtis Software Jeff Davis520 South Main Street 800/648-2377Suite 2521 216/376-7665Akron, OH 44311 Ext. 211

Cydata Sheryl BreitfelderOne Cycare Plaza Ste. 500 319/556-3131Dubuque, IA 52001

Dagar Ron AngeloneBox 8776 401/944-8856Cranston, RI 02920



DMERC CertifiedSoftware Vendors(Cont'd) DataHouse Jim Collins

One Perimeter Park South 205/972-9292Suite 100 SouthBirmingham, AL 35243-2343

Dezine Associates Ray Asmar/ MSP758 State Hwy. 18, Suite 110 Jeff BloomEast Brunswick, NJ 08816 800/447-7370

Digital Simplistics Paul Peterson11505 W. 83rd Terrace 913/894-0081Lenexa, KS 66214

Dynamic Energy Systems Sandra Myers710 East Park Blvd 214/423-5171Suite 206Plano, TX 75074

Dynamic Sourcing Jorge Diaz Certified for all CMNs6091 Johns Road #7 813/881-1132 except DMERC CMNTampa, FL 33634 08.01

Effective Solutions Tom Stroud5220 75th St., Suite 5 806/794-9114Lubbock, TX 79424

Elcomp Barbara McMaster Certified only for681 Anderson Dr. 412/937-0690 claims w/o CMNs;Pittsburgh, PA 15220 MSP

General Computer Corp. Len C. Stusek2045 Midway Dr. 800/521-4548Twinsburg, OH 44087

Healthcare Computer Corp. David Pippin Certified for all CMNs4508 Oakfair Blvd. 813/622-8835 except DMERC CMNTampa, FL 33610 10.01 & HCFA-484

Health Team Carla Burhanan1202 Olympic Blvd. 310/452-3535Santa Monica, CA 90404

Home Healthcare Systems Kelly Thomas2008 Wildbriar Court 502/222-4264LaGrange, KY 40031

Info Quest Netton Mehta314 E. Main St. 302/456-3392Newark, DE 19711

Info Services Tommy Ladner Certified for all CMNs155 McCormack Drive 601/977-8966 except DMERC CMNRidgeland, MS 39157 10.01

Kiyo Systems Richard SakaauraP.O. Box 3239 714/556-5667Newport Beach, CA 92659

MCS, Inc. Chris DiCarlo400 Penn Center Blvd. 412/823-7440Pittsburgh, PA 15235-5658

MS Group, Inc. Henry Meyer Certified only for9380 Sunset Dr., #B-135 305/279-7917 claims w/o CMNsSuite 850Miami, FL 33173




Management By Information Lee Hartz Certified for all CMNs100 S. University, Ste. 409 501/661-0386 except DMERC CMN 09.01Little Rock, AR 72205 & 10.01

MED 2000 Frank SmithP.O. Box 489 310/316-9110Redondo Beach, CA 90277

Medic Computer Systems James Bengel8601 Six Forks Rd. 919/847-8102Raleigh, NC 27615

Medical Business Svcs. Gary Foster Certified only for10201 W. Markham 501/223-2080 DMERC CMN 04.01Suite 206Little Rock, AR

Medical Data Systems Greg Kirsch1267 W. Bagley 800/343-5854Berea, OH 44017

Medical Office Software Marc Workman MSPP.O. Box 27089 303/271-0944 Certified for P/O & claimsSuite 100 South w/o CMNDenver, CO 80227

Medical Solutions Bill Moore MSP1 Sugar Creek 800/264-4674Sugarland, TX 77478

Mega West Systems Scot Wood345 Bearcat Dr. Doug FieldingSalt Lake City, UT 84115 801/487-0788

Micro Clinique Eugene Vasliescu11435 Bronzdale Dr. 703/264-0882Oakland, VA 22124

Micro Edge Jim Popp1029 E. Main St. 203/348-0297Stanford, CT 06902

Microsys Computing Inc. Agit Kumar784 Boardman Canfield Road 216/348-0297Stanford, CT 06902

Mid-South Business Systems Paul Holt Certified only for DMERC3318 N. Watkins 901/358-9236 CMN 04.01Memphis, TN 38127

Newman, Terry Terry Newman9171 Wilshire Blvd., Ste. 206 800/227-5534Beverly Hills, CA 90210

Prism Mary Walker Other Payer1700 N. Lebanon Street 800/223-3828Lebanon, IN 46052

Pro Business Systems, Inc. Bonnie Madril6266 N. “W” St., #216 904/479-9035Pensacola, FL 32533

Professional Financial Service Marshall FrymanP.O. Box 58206 813/866-2023St. Petersburg, FL 33715

DMERC CertifiedSoftware Vendors(Cont'd)


Promed Systems Inc. Wayne Gilbert221 Whitney Ave. 203/773-8255New haven, CT 06511

QS1 Marty Winters Other PayerP.O. Box 6052 803/578-9455Spartanburg, SC 29304

Reimbursement Services Brent Mattox orP.O. Box 27145 Ken HartGreenville, SC 29616 803/458-8884

Rich Ware, Inc. Rich Rohde12750 SW Pacific Hwy., #104 503/620-6862Tigard, OR 97223-6138

Rockhopper Systems, Inc. Todd McCoy10985 N. Harrell’s Ferry 504/272-9125Suite FBaton Rouge, LA 70816

Rollins Healthcare Data Sys. Jay Linton23100 Providence Dr. 810/423-7200Southfield, MI 48075

Sandata, Inc. Pat Matthews48 Harbor Park 516/484-0700Port Washington, NY 11050

Softcare Jim Highsmith828 W. Taylor St. 404/229-5294Griffin, GA 30223

Source Computing, Inc. Dick Brothers MSP627 S. 48th St., Ste. 100 602/829-7270Tempe, AZ 85281

Spectrum Software Rick Long3846 Faulkner Dr. 800/TEAM 289P.O. Box 111546 615/333-1900Nashville, TN 37222-1546

Standard Business Systems Rebecca McNeeley25675 Loraine Road 216/779-4070North Olmstead, OH 44070

Telecare DME Systems Mike Pollock138 N. Moon Ave., Suite A-1 813/654-2422Brandon, FL 33510

Tropical Software Ted Wade Other Payer6860 Gulfport Blvd. 813/367-8061Suite 270St. Petersburg, FL 33730

Wallaby Software Narendra Goradia10 Industrial Avenue 201/934-9333Mahwah, NJ 07430

Wismer-Martin Larry Stansbury12828 N. Newport Highway 800/231-7477Mead, WA 99021


DMERC CertifiedSoftware Vendors(Cont'd)


4 C’s Medical Billing Charles CourimP.O. Box 720905 619/868-4932Pinon Hills, CA 92372

XVIII-B Medi Mart-1 Christine Kingston8121 10th Avenue North 612/595-6308Golden Valley, MN 55427

Accu Quick Mary Nowlin-Delay1325 Debrick Road 503/683-4966Eugene, OR 97401

Advantage Business Services Jackie Hutchins4420 S. Lee Street, Suite 201 404/271-1009Buford, GA 30518

ASAP Medical Billing Services Sue Corcoran600 N. Mountain Ave. #B-200 909/982/4822Upland, CA 97786

Campbell Enterprises 515/932-5258116 3rd Ave. WestAlbia, IA 52531

Claim-Aid John BottegoP.O. Box 1710 713/261-8686Sugarland, TX 77487-1710

Claimcare Paul Fagan520 South Main Street 800/648-2377Suite 2521 216/376-7665, Ext. 214Akron, OH 44311

Comp U Claims Lauren Carson30 Bull St. 401/849-4702Newport, RI 02840

Complete Billing Systems506 Athena DriveBelmont, PA 15626

Cornell Med Claims Jay Cornell3 Academy St. 908/464-3636N. Providence, NJ 07974

DME Services of Texas Terry HendersonP.O. Box 870215 214/226-8055Mesquice, TX 75187-0215

Del Crane Medical, Inc. Dave Gidley520 South Main Street 513/831-2544Lebanon, OH 45140

Electronic Medical Billing Thomas LiuE. Codey Dr. Ste. 200-N 909/824-5903Colton, CA 92324

HMS Healthcare Mgmt. Ester Aptner127 Route 59 914/425-8856Muncy, NY 10952

Haugen Insurance Rita HaugenRR #1 Box 74 701/683-4637Lisbon, ND 58054

Health Team Carla Burhanan1202 Olympic Blvd. 310/452-3535Santa Monica, CA 90404


DMERC CertifiedElectronic BillingServices


Healthcare Computer Corp. David Pippin Certified for all CMNs4508 Oakfair Blvd. 813/622-8835 except DMERC CMNTampa, FL 33610 10.01 & HCFA-484

Hi Tech Health Care Services Jim Morrell589 N. 3050 E #1 801/673-3002St. George, UT 84470

Integrated Med. Mgmt. Svcs. Kent HartmannP.O. Box 279 615/344-6066Harrison, TN 37341

LTC Data Service Barb Betts3412 Georgia St. 314/754-6350P.O. Box 444Louisiana, MO 63353

Lemay’s Professional Billing Kristin Lemay980 Carson Drive 408/737-7429Sunnyvale, CA 94086

Martello & Associates Herbert Martello2621 Whiteford Road 410/452-9041Whiteford, MD 21160

Med-90, Inc. Tom Grommett1432 Hanley Industrial Ct. 314/961-2666St. Louis, MO 63144

Med Tech Services John Hanley14645 S.W. Osprey Dr. #213 503/578-1692Beaverton, OR 97007-8123

Medi-Claims Express Ed ScottP.O. Box 2282 912/741-1405Macon, GA 31203

Medical Data Management Norman Burrell Other Payer37800 Mound Rd. 313/268-8440Sterling Heights, MI 48310

Medical Billing Service Kevin Smith1728 Race St. 303/331-0651Denver, CO 80206

Medical Outpatient Service David Audibert105 Clark Drive 203/257-7111E. Berling, CT 06023

Medicare Claims Management Donna Ferguson9002 N. Meridia 317/573-4244Indianapolis, IN 46260

Medinet Supply Co. Curt McLeod/Kelly10700 S.W. Hillsdale Hwy. #660 816/756-5228Beaverton, OR 97005

Nursing Facility Services Nola Devitt CMNs, MSP, MG3030 Gillham Road 816/756-5228Kansas City, MO 64108

Oklahoma Consulting Services Philip Heiliger4230 N. Santa Fe 405/525-0355P.O. Box 159Oklahoma City, OK 73118

Physician's Filing Service Debbie RoderickP.O. Box 2336 618/244-3322Mt. Vernon, IL 62864


DMERC CertifiedElectronic BillingServices(Cont'd)


Premier Billing Service Francine Fields3920 Augusta Highway 803/787-9255West Columbia, SC 29170

Professional Billing Service Pat McCracken5337 AL S. Campbell Ann DeckerSpringfield, MO 86810 417/887-5568

Professional Claim Services Julie Hallfrisch3500 7th St. NE 406/452-8818Great Falls, MT 59404

Provider Billing Services Jeff Donahue Certified only7401 N. Broadway, Suite 450 303/430-8003 for HCFA-484Denver, CO 80221

Reimbursement Services Brent Mattox/P.O. Box 27145 Ken HartGreenville, SC 29616 803/458-8884

SNF Billing Service Roberta KilpatrickP.O. Box 1001 201/837-8170Teacneck, NJ 07666

SSI Medical Services Pam Ryan4349 Corporate Road 803/740-8412Charleston, SC 29405

Specialty Claims Michelle Milby125 Heatherton Circle 502/932-3749Suite 360 Clausen BuildingGreensburg, KY 42743

Summit Health Care Services Nick Rossi204 Donohoe Rd. 800/432-7788Greensburg, PA 15701

Telecare DME Systems Mike Pollock138 N. Moon Ave., Suite A-1 813/654-2422Brandon, FL 33510

Universal Medical, Inc. Keith JonesP.O. Box 451107 404/321-1918Atlanta, GA 30345

Budget Computer Systems Eddie Muniz10500 N.W. 26th St. 305/477-7770Bldg. 101Miami, FL 33172

Companion Technologies Frank Harris Other PayerI-20 East @ Alpine Road 803/699-2625Columbia, SC 29219

Medical Data Systems Greg Kirsch1267 W. Bagley 800/343-5854Berea, OH 44017

Noble House Richard Mehan200 W. Palmetto Park Rd. 407/392-6700Boca Raton, FL 33432

TeleClaims, Inc. Johnnie Farley Certified only820 Shades Creek Pkwy. 203/879-3022 for claims w/oSuite 1000 CMNsBirmingham, AL 35209


DMERC CertifiedElectronic BillingServices(Cont'd)

DMERC CertifiedElectronicClearinghouses


PLACE OF SERVICE(POS)

All claims filed to the DMERC must include a two digit POS code in Item 24b of the HCFA-1500 (12/90) form. Claims filed without POS information (or with an invalid POS code) willcause processing delays. Only the following POS codes should be submitted to theDMERCs.

POS Definition12 Home31 Skilled Nursing Facility32 Nursing Facility33 Custodial Care Facility65 End Stage Renal Disease Treatment Facility

DMERCs do not have jurisdiction over equipment/items provided for use in a physician'soffice (POS 11). The POS code should indicate where the patient is to use the equipment/item, (e.g., patient's home), as opposed to where it was issued, (i.e., physician's office).

The following POS codes are valid for the noted categories of Durable Medical Equipment(DME):

I. Inexpensive or other routinely purchasedDurable Medical Equipment (DME) ........................................................12, 33

II. Items requiring frequent and substantial servicing ...................................12, 33III. Customized items

a. Prosthetic and Orthotics (P&O) ..................................................12,31,32,33b. DME ................................................................................................12,33

IV. Capped rental items .............................................................................12, 33V. Oxygen and oxygen equipment .............................................................12, 33VI. General prosthetic and orthotic devices ..................................12, 31, 32, 33, 65

P & O supplies, Parenteral and Enteral Nutrition (PEN) related itemsand supplies (These include IV poles used to administer PEN(E0776XA), urinary incontinence and ostomy supplies.)

VII. Surgical dressings .................................................................... 12, 31, 32, 33VIIl. Drugs (oral anticancer, those administered through DME) ........................12, 33

DMEPOS SUPPLIERSPECIALTYWORKSHOPSNOTICE

Palmetto Government Benefits Administrators (Palmetto GBA), the Medicare Region CDurable Medical Equipment Regional Carrier (DMERC), is sponsoring a series ofworkshops throughout the South and Southwest region. Beginning the last week of March1994, we will have workshop sessions covering the followingmedical specialties:

DME/OxygenVisionPEN/Ostomy, Urologicals & SuppliesProsthetics & Orthotics

We are inviting you and/or your staff to attend one of theseworkshops which will be held in various locations. Asworkshop locations are scheduled and confirmed, we willsend you an invitation.

You need only attend those workshop sessions whichpertain to the services you provide. There will be a $25.00fee per attendee for each workshop session. More informa-tion on how to register and where to send your payment will beincluded in your invitation.

As your Durable Medical Equipment Regional Carrier (DMERC) we value your input andknow it is vital to our continuing educational programs. To tap into your knowledge and growthrough your experience, we are organizing Supplier Advisory Committees (SACs). SACsoffer a forum for the exchange of information and ideas between suppliers and the DMERCs.The membership of each committee will consist of two DMERC staff members and up to 15members from the supplier community.

We have received an overwhelming number of requests from suppliers who would like toparticipate in these groups. As these committees are organized we will publish thisinformation in future issues of the DMERC Medicare Advisory.

SUPPLIER ADVISORYCOMMITTEE (SACS)

AlabamaArkansasColoradoFlorida

GeorgiaKentuckyLouisianaMississippi

New MexicoNorth CarolinaOklahomaPuerto RicoSouth CarolinaTennesseeTexas

Virgin Islands

Please bringyour DMEPOSSupplier Manual!

Palmetto GovernmentBenefits Administrators


PROFESSIONALRELATIONS STAFF

The entire professional relations staff at Palmetto GBA is committed toproviding a quality educational program for our suppliers, physicians andbeneficiaries. Serving as Legislative Specialists with Palmetto GBA sinceJune 1993 are Ben Brantley and Susan Duncan. Joining us in January 1994is our new ombudsman, Cheryl Heller.

Ben BrantleyLegislative Specialist

Ben Brantley is a native of Columbia, South Carolina. He earned his Bachelorof Arts in History from the University of South Carolina in May of 1993. Whilein college he worked with the Public Affairs division of Blue Cross and BlueShield of South Carolina, serving as a Legislative Liaison. He also worked forU.S. Senator Ernest Hollings and South Carolina Senator Warren Giese.Experienced as an independent legislative consultant prior to joining theProfessional Relations staff, Ben looks forward to his work as a LegislativeSpecialist for Palmetto GBA.

Susan DuncanLegislative Specialist

Susan Duncan is a native of West Columbia, South Carolina. She attendedthe University of South Carolina where she earned her Bachelor of Arts inEnglish in 1988. She continued her education, receiving her Masters in MassCommunications also from USC in 1992. While in school, Susan was acolumnist, as well as business editor for a local newspaper. Her work in theLieutenant Governor's office, with U.S. Senator Ernest Hollings, and SouthCarolina Senator Nikki Setzler gives her a solid background for her position asLegislative Specialist at Palmetto GBA.

Cheryl HellerOmbudsman

Cheryl comes to the Region C DMERC from the Medicare Part B carrier fornorthern California, Blue Shield of California, where she has been employedfor the past nine years. Cheryl functioned in a number of capacities, e.g.,claims examiner, customer service representative, supervisor of accounting,fair hearings, customer service, DME and oxygen processing unit, ProviderCompliance Monitoring and for the past two years as an ombudsman. Shebrings a wide range of knowledge and experience to the professional relationsstaff at Palmetto GBA, as the ombudsman for central and western Texas,Oklahoma and New Mexico. Cheryl continues to work toward a degree inbusiness administration while studying to become fluent in Spanish. She isexcited about relocating to Dallas, Texas and looks forward to exploring all thesurrounding areas.


*OMBUDSMEN ADDRESSES AND THEIR TERRITORIESOmbudsmen are located in their territories as shown below, and are making on-site, educational visits tosuppliers, as well as organizing the Supplier Advisory Committees. Cheryl Heller, as the ombudsman for centraland western Texas, Oklahoma and New Mexico, will be moving to a permanent location within her territory soon.When her permanent business location is confirmed, it will be published in the DMERC Medicare Advisory. Allcorrespondence for the ombudsmen should be sent to Palmetto Government Benefits Administrators,Professional Relations Department, P.O. Box 100141, Columbia, SC 29202-3141.

* Ombudsmen are those who investigate reported complaints, reports findings, and help to achieve equitablesettlements, through training and educating of the supplier community.

The portion of the state (Texas and Florida) which the ombudsman covers.

SC

KY NC

AR

NM

OK

TXAL

FL LA

MS

VI

FL

PR

GA

TN

Claudia AmorteguiP.O. Box 100141Columbia, SC 29202-3141(803) 735-1034 Ext. 5714

Sheri ThompsonP.O. Box 99247Raleigh, NC 27624-9247(919) 848-3203

Cheryl HellerP.O. Box 100141Columbia, SC 29202-3141(803) 735-1034 Ext. 5724

Keith O. Smith10991-55 San Jose Blvd.Suite 139Jacksonville, FL 32223(904) 287-6860

Bobby SmithP.O. Box 9225Jackson, MS 39286(601) 366-4983

CO

TX

Laurie L. Leonard9715 W. Broward Blvd.Suite 244Plantation, FL 33324(305) 370-6295

Alan Jay House#43425 Highland Park VillageSuite 100Dallas, TX 75205-2785(214) 522-9955

Frank WhiteP.O. Box 420062Atlanta, GA 30342-0062(404) 257-9540


PRIORAUTHORIZATIONPROCESS

Prior authorization was designed to determine the medical necessity of the followingitems before delivery for both assigned and non-assigned Medicare claims: Transcu-taneous Electronic Nerve Stimulators (TENS), Power Operated Vehicles (POVs) andSeat Lift Mechanisms.

Suppliers should encourage physicians to utilize this program. Prior authorization is notmandated by the DMERC, but is offered as a service to physicians and beneficiaries.

The medical information required to make a medical necessity determination must beprovided by the attending physician/office staff. Palmetto GBA encouragesphysicians or their office representatives to call our dedicated prior authorization linewith the following information: diagnosis, patient's name, Health Insurance ClaimNumber (HICN), address, and telephone.

The physician or physician office representative should be prepared to answer theclinical questions on the CMN pertinent to the item being reviewed for medicalnecessity.

Upon initiating the prior authorization process, we recommend that the physician havethe patient's medical records available. The reviewer will follow this general procedure:

a. The reviewer will discuss each case with the physician using the DMERC medicalpolicies and complete a CMN for the case via telephone.

b. If the reviewer makes an "authorized" decision, this does not guarantee paymentby Medicare for the product but rather approves the medical necessity of the item.The Medicare eligibility of the patient must be determined at the time the claim issubmitted. An "authorized" determination is a confirmation that the patient'scondition as described meets the criteria in the DMERC medical policies for thespecified item.

c. If the reviewer determines that the item does not meet the medical necessitycriteria, the case will further be discussed with the physician. A denial of theauthorization request means that Medicare Part B will not cover the item for theconditions described. When the request for authorization is denied due to lack ofmedical necessity, the patient may choose to obtain the item and assume financialliability for it.

d. When a prior authorization request has been processed, the reviewer will issue awritten confirmation of the decision to the physician and to the patient. A priorauthorization control number will be given to the provider on all approved requests.The prior authorization number must be recorded in Item 23 of the HCFA-1500 (12/90) form and should be indicated on the prescription for both assigned and non-assigned claims.

The authorization addresses the specific time period during which the item must beobtained, the item authorized, and a prior authorization number.

We suggest the following tips for a supplier to facilitate the prior authorization processand subsequent claim payments: Provide education to the physician on the appropriateCMN form. This will better prepare the physician to have the necessary information athand when answering our questions. Remind the physician that the patient must havebeen examined by him/her within 30 days of the prior authorization request. Encouragethe physician to use the dedicated prior authorization telephone number, (803) 735-9353.

NOTE: This line is staffed by clinicians only and should not be used by suppliers.

When prior authorization is not obtained, the appropriate DMERC CMNs need to besubmitted for codes E0627, E0628, E0629, E0720, E0730, E0731 and E1230.

Prior AuthorizationTelephone Number


SERVICE ACCESS We have experienced some difficulty in providing the level of telephone service we wouldideally like to offer. To improve your opportunity to reach us directly we recommend youcall us during early morning and late afternoon hours when our telephone lines are lessbusy. We also would encourage you to utilize our Audio Response Unit (ARU), and refrainfrom checking the status of claims before 30 days have elapsed since submission.Accessing the ARU may enable you to get answers to some of your questions withoutwaiting. All that is needed to access the ARU is a touch-tone telephone, your NationalSupplier Clearinghouse (NSC) assigned supplier number, the beneficiary's Medicarenumber, and the date of service.

With a touch-tone telephone, you can:

t Get the latest information on Medicare issues.t Receive on-line, detailed claims information regarding:

Amounts applied to the deductibleAmounts paid on a claimAdjusted payment informationLine item informationClaim denial informationClaim pending information

The ARU can be accessed during extended business hours, (when our computer systemis available). You can transfer out of the ARU to talk to a team member during regularbusiness hours.

Audio Response Unit: Use your Dedicated Work Team "800" number.(Refer to Section 21 of your DMEPOSSupplier Manual.)

Monday - Saturday7:00 a.m. - 7:00 p.m. (Eastern Time)

1. Q Can Terbutaline Sulfate be billed under code J3105?A No. Code J3105 represents an injectable drug and is not billable to the DMERCs. As a bronchodilator

medication, terbutaline sulfate may be billed to the DMERC with code J7699.

2. Q How are compound drugs billed?A Compound drugs have previously been billed with local carrier codes. These local codes will no longer be

valid for claims submitted to the DMERCs. Code J7699, a Not Otherwise Classified (NOC) bronchodilatordrug code, should be used, along with the name of the drug and the indication that it has been compounded.

3. Q How are utilization limits tracked for ostomy supplies?A Utilization limits are tracked by comparing the number of items billed to the span of time shown by the "from"

and "to" date of service on the HCFA-1500 (12/90) claim form.

4. Q What is the formula for calculating cal/gm/day for parenteral patients?A This formula can be found on page 19.7 of your DMEPOS Supplier Manual.

Weight (lbs) ÷ 2.2 = Weight in KilogramsPrescribed calories per day ÷ Weight (kg) = Calories/Kg

The number of calories per day would have to be determined from the components of the patient’s parenteralformula.

These questions were submitted to Palmetto GBA by Region C suppliers, and the answers are being published so that allmay benefit.

Q&A Providing answers to your questions/concernson an on-going basis.


UNIQUE PHYSICIANIDENTIFICATIONNUMBER (UPIN)DIRECTORY:HOW TO OBTAIN

1) "UPIN directories are available upon request and free of charge tophysicians, suppliers and billing services. You may obtain UPIN directoriesfrom the carrier in the state in which the ordering physician renders the serviceor resides, since some physicians are in border states and may renderservices in two states. You may also contact the ordering physician directlyfor his or her UPIN."

1) DMEPOS Region C Supplier Manual, page 1.17

PEN SUPPLY ANDADMINISTRATIONKITS

The DMERC Anti-Fraud Unit reminds PEN suppliers to bill the actual amounts/days used and not automatically a month's supply for PEN supplies andadministration kits.

1) "PEN Supply and Administration Kits

Payment for supply and administration kits is based on a per diem rate.The total number of actual days used should be entered in Item 24G of theHCFA-1500 (12/90) form or in the Days/Units field for EMC transmission."

1) DMEPOS Region C Supplier Manual, page 19.8

The suppliers identified below are being excluded from participation in the TitleXVIII (Medicare) program. This exclusion is effective as of March 1, 1994, perJames F. Patton, Director, Health Care Administrative Sanctions, Office ofInvestigations and Enforcement.

Jo Beth Cosby, Owner of DME Company9 Country Meadow LaneLexington, South Carolina 29073

Authority: 1128(a)(1) DOB: 06/21/35Period of Exclusion: 5 Years SSN: 250-56-23174-93-40044-9 Provider No.: Unknown

Durable Home Medical Equipment, Inc., DME Supply Company9 Country Meadow LaneLexington, South Carolina 29073

Authority: 1128(b)(8)Period of Exclusion: 5 Years4-93-40044-9

ANTI-FRAUD ANDABUSE UNIT

MEDICARE PART BCARRIER'S MANUAL:HOW TO OBTAIN

An individual or organization interested in obtaining the Medicare Part BCarrier's Manual and its revisions, as well as any replacement issues, at a costof $1,043.00* may do so by directing their orders to:

Superintendent of Documents or National Technical Information ServiceP.O. Box 371954 Department of CommercePittsburgh, PA 15250-7954 5825 Port Royal Road(202) 783-3238 Springfield, VA 22161

(703) 487-4630

* May increase based on inflation factor.


The following matrix contains the Other Carrier Name and Address (OCNA)Number List, alphabetized by the name of the Medigap Insurance Company. Ifmultiple entries are listed for the same Medigap Insurance Company, then afurther match must be done by address. If you cannot locate the correct MedigapInsurance Company name and associated address, then you should write thecomplete name and address of the Medigap Insurance Company in Item 9c and9d as outlined in the HCFA-1500 (12/90) form instructions.

USING THE OCNAMATRIX

BANKERS COMMER LIFE INS C............................... 75240B001BANKERS FIDELITY LIFE INS ................................... 30319A003BANKERS LIFE & CASUALTY ................................... 02888B001 BRUCE BALCOM 895 POST ROAD WARWICK, RI 02888-336195BANKERS LIFE & CASUALTY ................................... 60630B001 4444 W. LAWRENCE AVE. CHICAGO, IL 60630-254644BANKERS MULTIPLE LINE........................................ 75221B001BCBS MOUNTAIN STATE.......................................... 25325B001BCBS OF ALABAMA .................................................. 35244B001BCBS OF ARIZONA .................................................... 85069B001BCBS OF ARKANSAS................................................ 72203B001BCBS OF CALIFORNIA .............................................. 91365B001 ATTN: MEDIGAP UNIT PO BOX 4162 WOODLAND HLS, CA 91365-416262BCBS OF CALIFORNIA .............................................. 91470B001 P.O. BOX 7000 VAN NUYS, CA 91470BCBS OF CALIFORNIA .............................................. 94612B001 1950 FRANKLIN ST. OAKLAND, CA 94612-510350BCBS OF COLORADO ............................................... 80203B001BCBS OF CONNECTICUT.......................................... 06473B001BCBS OF DELAWARE ............................................... 19801B001BCBS OF FLORIDA .................................................... 32202B001BCBS OF GEORGIA ................................................... 31908B001BCBS OF ILLINOIS..................................................... 60601B001BCBS OF IOWA .......................................................... 50309B001BCBS OF KANSAS..................................................... 66629B001BCBS OF KANSAS CITY ............................................ 64141B001BCBS OF KENTUCKY ................................................ 40223B001BCBS OF LOUISIANA ................................................ 70898B001BCBS OF MAINE ........................................................ 04106B001BCBS OF MARYLAND................................................ 21117B001BCBS OF MASSACHUSETTS.................................... 02171B001BCBS OF MEMPHIS ................................................... 38101B001BCBS OF MICHIGAN.................................................. 48226B001BCBS OF MINNESOTA .............................................. 55164B001BCBS OF MISSISSIPPI .............................................. 39215B001BCBS OF MISSOURI .................................................. 63108B001BCBS OF MONTANA .................................................. 59604B001BCBS OF NATL CAPITAL AR .................................... 20065B001BCBS OF NEBRASKA ................................................ 68180B001BCBS OF NEVADA ..................................................... 89520B001BCBS OF NEW HAMPSHIRE..................................... 03306B001BCBS OF NEW JERSEY ............................................ 08206B001BCBS OF NEW MEXICO............................................ 87112B001BCBS OF NEW YORK (EMPIRE) ............................... 10016B001BCBS OF NEW YORK (MURRAY HI .......................... 10156B001BCBS OF NEW YORK (CENTRAL) ............................ 13221B001BCBS OF NEW YORK ................................................ 14604B001BCBS OF NEW YORK (NE) ........................................ 12205B001BCBS OF NEW YORK (UTICA-WAT.......................... 13501B001BCBS OF NEW YORK (WESTERN) ........................... 14240B001BCBS OF NORTH CAROLINA .................................... 27702B001BCBS OF NORTH DAKOTA ....................................... 58121B001BCBS OF OHIO .......................................................... 43697B001 P.O. BOX 943 TOLEDO, OH 43697-094343

Company Name OCNA #

A & H CLAIMS ............................................................ 60630A001AARP (PRUDENTIAL) ................................................ 18936A001ACADEMY LIFE INS CO ............................................ 30328A001ACORDIA BENEFITS ................................................. 92806A001ACORDIA LOCAL GOV’T SVCS ................................ 46250A001ACORDIA SENIOR BENEFITS .................................. 46250A001ADMINISTRATIVE SRVS INC .................................... 30345A001AFLAC ........................................................................ 31999A001 (AMER FAMILY LIFE ASSUR CO)AGRICULTURE INS ADMIN ....................................... 83501A001 AICI (ASSOC INS COS INC) ..................................... 46250A001AID ASSOC FOR LUTHERANS ................................. 54919A001AIG LIFE INS CO ........................................................ 19801A001AIROMD MAILHANDLERS INS .................................. 20855A001ALLIANCE HLTH BEN PLAN...................................... 20065A001ALTA HLTH STRATEGIES ......................................... 21201A001AMALGAMATED LIFE & - 79 ..................................... 60607A001AMER ASSOC ............................................................ 90712A001AMER BANKERS INS ................................................. 76101A001AMER BANKERS INS CO OF FL ............................... 33157A001AMER COMBINED LIFE............................................. 19047A001AMER COMMUNITY MUTUAL ................................... 48152A001AMER EXCHANGE LIFE INS CO............................... 75221A001AMER FAMILY MUTUAL INS CO............................... 53783A001AMER GENERAL LIFE & ACC ................................... 37250A001AMER HARDWARE MUTUAL .................................... 55440A001AMER HOECHST PER ............................................... 60558A001AMER INCOME LIFE INS ........................................... 76702A001AMER INDEP LIFE INS CO........................................ 19406A001AMER INS CO OF TX................................................. 75266A001AMER INTEGRITY INS CO ........................................ 19101A001AMER LIFE AND ACC ................................................ 75221A002AMER LIFE INS CO.................................................... 31999A001AMER NAT’L INS CO ................................................. 77553A001AMER PROGRESS L&HIC OF NY ............................. 10509A001AMER PROTECTIVE LIFE INS CO............................ 38732A001AMER REPUBLIC INS CO ......................................... 50301A001AMER SERVICE LIFE INS CO ................................... 76107A001AMER STD LIFE & ACC CO....................................... 73702A001AMER TRAVELLERS INS .......................................... 18976A001 ATTN: MEDIGAP 1800 STREET ROAD WARRINGTON, PA 18976-250300AMER TRAVELLERS INS .......................................... 19020A001 3220 TILLMAN DRIVE BENSALEM, PA 19020-202820AMERICARE INS ........................................................ 37215A002AMOCO CASUALTY & INDEM................................... 68102A001AMVETS INS PLANS ................................................. 43216A001APPALACHIAN LIFE INS CO ..................................... 25701A001ARMCO MED INS SVC CT......................................... 43085A001ASSOC DOCTORS HLTH & LIFE .............................. 35289A001ASSOC INS COS INC (AICI) ...................................... 46250A001ASSOC MUT HOSP SRVC......................................... 35289A001ASSOCIATED LIFE INS CO ....................................... 46206A001ATCHISON TOPEKA .................................................. 66612A001ATLANTIC AMER INS CO .......................................... 30319A001ATLANTIC AMER LIFE INS ........................................ 30319A002ATLANTIC AMER/BKRS FIDEL ................................. 30319A003ATLANTIC COAST INS CO ........................................ 30503A001ATLANTIC INS CO OF SA .......................................... 78714A001ATLANTIC & PACIFIC INS CO................................... 30359A001AUTO OWNERS LIFE INS CO ................................... 48909A001AWARE GOLD............................................................ 55164A001

Company Name OCNA #


Company Name OCNA # Company Name OCNA #

COMBINED INS OF AMERICA .................................. 19047C001COMBINED UNDERWRITERS LIF ............................ 75710C001COMMERCIAL LIFE INS ............................................ 31401C001COMMONWEALTH INS CO ....................................... 43235C001COMMONWEALTH NATL LIFE IN ............................. 38732C001COMMUNITY MUTUAL INS ....................................... 45206C001COMPANION HEALTH CARE .................................... 29223C001COMPCARE HLTH SVCS INS CO ............................. 53202C001COMPLETE HEALTH ................................................. 35202C001CONFEDERATION LIFE INS CO ............................... 29418C001CONSUMER UNITED INS CO.................................... 20063C001CONTINENTAL AMER LIFE ....................................... 19850C001CONTINENTAL ASSURANCE .................................... 30326C001CONTINENTAL CASUALTY ....................................... 60604C001CONTINENTAL GENERAL INS .................................. 68124C001CONTINENTAL GENERAL INS CO ........................... 67201C001CONTINENTAL LIFE INS CO ..................................... 37024C001COOPERATIVA DE SEGUROS DE V........................ 00936C001CORNING GROUP INS DEPT .................................... 14830C001CORPORATE LIFE INS CO ....................................... 19381C001COSMOPOLITAN LIFE INS CO ................................. 91365C001CROLEY LIFE INS CO ............................................... 75644C001CRUS AZUL DE PUERTO RICO ................................ 00936C002CUNA MUTUAL INS CO ............................................. 35124C001CUSTOM CARE.......................................................... 28235C001DALLAS GENERAL LIFE............................................ 75221D001DEANCARE ................................................................ 53705D001DIRECT OLIN ............................................................. 06497D001DURHAM LIFE INS CO .............................................. 27611D001EARLY AMER LIFE INS CO ....................................... 55121E001EASY CHOICE USA ................................................... 25301E001EBA ............................................................................. 64193E001EDS FEDERAL CORP ................................................ 66604E001EDS MEDICAL............................................................ 95852E001EDUCATORS MUTUAL .............................................. 84107E001EGIP ........................................................................... 73124E001ELECTRIC MUTUAL BENEFIT A............................... 84127E001ELECTRONICS DATA SYSTEM ................................ 82003E001EQUALIZER................................................................ 48226E001EQUITABLE LIFE ASSN SOC O................................ 18042E001 300 MORRISON AVENUE EASTON, PA 18042EQUITABLE LIFE ASSN SOC O................................ 84110E001 ATTN: GENEVIEVE GALLOWAY PO BOX 2460 SALT LAKE CITY, UT 84110-246060EQUITABLE LIFE ASSURANCE CO.......................... 66205E001 FAIR OFF CTR SHAWNEE MISSION, KS 66205EQUITABLE LIFE ASSURANCE CO.......................... 87190E001 PO BOX 3310 ALBUQUERQUE, NM 87190-331010EXECUTIVE FUND INS CO ....................................... 90403E001FARM FAMILY LIFE INS CO ...................................... 12201F001FARMERS STOCKMAN INS ...................................... 99210F001FEDERAL HOME COMPANIES ................................. 49017F001FEDERAL HOME LIFE ............................................... 53214F001FEDERAL HOME LIFE INSURANCE ......................... 32887F001FEDERAL KEMPER INS CO ...................................... 62526F001FELRA ........................................................................ 21212F001FHP LIFE INS CO ....................................................... 92708F001FIC INS GROUP ......................................................... 78714F001FIREMAN’S FUND EMPLOYERS IN .......................... 55440F001FIRST CENTENNIAL LIFE INS .................................. 80522F001FIRST CONTINENTAL LIFE ....................................... 15230F001FIRST HEALTH OF AZ INC ........................................ 85351F001FIRST NATL LIFE ....................................................... 36104F001FLEET RESERVE ASSOC ......................................... 20037F001FOREMOST LIFE INS CO.......................................... 49501F001FOUNDATION HEALTH PLAN................................... 95670F001FOUNDATION HLTH PLAN........................................ 93712F001 PO BOX 792 FRESNO, CA 93712-079292FOUNDATION HLTH PLAN........................................ 95608F001 5030 EL CAMINO AVE CARMICHAEL, CA 95608-465030

BCBS OF OHIO .......................................................... 44115B001 ATTN: MEDIGAP UNIT 2060 E 9TH ST CLEVELAND, OH 44115-130460BCBS OF OKLAHOMA ............................................... 74102B001BCBS OF OREGON ................................................... 97207B001BCBS OF RHODE ISLAND ........................................ 02903B001BCBS OF SOUTH CAROLINA ................................... 29219B001BCBS OF SOUTH DAKOTA ....................................... 57104B001BCBS OF TENNESSEE ............................................. 37402B001BCBS OF TEXAS ....................................................... 75080B001BCBS OF UTAH ......................................................... 84130B001BCBS OF VERMONT ................................................. 05601B001BCBS OF VIRGINIA ................................................... 23230B001BCBS OF WISCONSIN............................................... 53203B001BCBS OF WYOMING ................................................. 82003B001BD OF PENSIONS - PRESBY CH.............................. 19101B001BELL UNIT .................................................................. 60690B001BENEFICIAL LIFE INS CO ......................................... 97207B002BENEFIT TRUST LIFE ............................................... 63127B001BENEFIT TRUST LIFE INS CO .................................. 60045B001BLUE CROSS OF ARIZONA ...................................... 85002B001BLUE CROSS OF CALIFORNIA ................................ 93031B001BLUE CROSS OF IDAHO........................................... 83707B001BLUE CROSS OF PA-INDEPENDEN ........................ 19103B001BLUE CROSS OF PENNSYLVANIA .......................... 15242B001BLUE CROSS OF WASHINGTON ............................. 98111B001BLUE SHIELD OF CALIFORNIA ................................ 94120B001 PO BOX 7168 SAN FRANCISCO, CA 94120-716868BLUE SHIELD OF CALIFORNIA ................................ 95667B001 SENIOR SERVICE CTR PO BOX 67-8010 PLACERVILLE, CA 95667-801010BLUE SHIELD OF IDAHO .......................................... 86501B001BLUE SHIELD OF KING COUNTY ............................. 98111B002BLUE SHIELD OF NORTH DAKOTA ......................... 58103B001BLUE SHIELD OF PENNSYLVANIA .......................... 17089B001BLUE SHIELD OF TENNESSEE ................................ 37212B001C M LIFE INS CO ....................................................... 06105C001CAL FARM BUR HLTH INS PRO ............................... 95851C001CAREAMERICA LIFE INS CO.................................... 91311C001CARLE CARE ............................................................. 61801C001CATHOLIC GOLDEN AGE INS .................................. 18505C001CELTIC LIFE INS CO ................................................. 60499C001CENTRAL BENEFITS MUTUAL I............................... 43216C001CENTRAL MASSACHUSETTS HLTH ........................ 01608C001CENTRAL RESERVE LIFE INS .................................. 44136C001CENTRAL SECURITY LIFE INS ................................. 75083C001CENTRAL STATES HLTH & LIFE .............................. 60631C001CENTRAL STATES INS ............................................. 60017C001CENTRAL STATES OF OMAHA ................................ 66134C001CERTIFIED LIFE INS CO ........................................... 60630C001 ATTN: MEDIGAP UNIT 4800 N KENNETH AVE CHICAGO, IL 60630-252500CERTIFIED LIFE INS CO ........................................... 75265C001 PO BOX 650209 DALLAS, TX 75265-020909CHRISTIAN FIDELITY LIFE ....................................... 75165C001CINCINNATI LIFE INS CO.......................................... 45250C001CITIZENS INS CO OF AMER ..................................... 78767C001CLINICIANS HLTH NETWORK .................................. 93301C001CNA INS CO ............................................................... 30345C001 2302 PARKLAKE DRIVE ATLANTA, GA 30345-290202CNA INS CO ............................................................... 60630C002 4444 W LAWRENCE AVE CHICAGO, IL 60630CNA/CONTINENTAL CASUALTY CO ........................ 37230C001COASTAL STATES .................................................... 73125C001COLONIAL .................................................................. 29306C001COLONIAL LIFE ......................................................... 29402C001COLONIAL PENN INS CO.......................................... 19181C001COLONIAL PENN LIFE INS ....................................... 29601C001COMBINED AMERICAN............................................. 60606C001


FOUNDATION HLTH PLAN........................................ 95865F001 PO BOX 255700 SACRAMENTO, CA 95865-570000FUTURE FINANCIAL .................................................. 53223F001GENERAL AMER LIFE ............................................... 63178G001GEORGIA LIFE & HLTH INS C.................................. 30301G001GERBER LIFE INS CO ............................................... 10601G001GH BENEFIT PLAN.................................................... 50306G001GLOBE LIFE & ACCIDENT INS C.............................. 75221U001GOLDEN CARE .......................................................... 38119G001GOLDEN INS CO ....................................................... 29202G001GOLDEN RULE INS CO ............................................. 46278G001 ATTN: TARA FLATT 7440 WOODLAND DR INDIANAPOLIS, IN 46278-172040GOLDEN RULE INS CO ............................................. 62439G001 712 11TH ST. LAWRENCEVILLE, IL 62439-231612GOLDSTAR HEALTH CARE ...................................... 43015G001GOOD SAM INS CO ................................................... 93121G001GOVERNMENT WIDE INDEM ................................... 83707G001GRAYS HARBOR MED BUREAU .............................. 98520G001GREAT AMER ............................................................ 32803G001GREAT AMER RESERVE INS CO ............................. 46032G001GREAT FIDELITY LIFE INS ....................................... 46801G001GREAT MIDWEST LIFE INS CO................................ 75218G001GREAT REPUBLIC INS CO ....................................... 98119G001GREAT WESTERN LIFE ............................................ 43215G001 1377 DUBLIN RD. COLUMBUS, OH 43215-108777GREAT WESTERN LIFE ............................................ 63105G001 7700 DOMMOMPE CLAYTON, MO 63105GREAT WESTERN LIFE ............................................ 80201G001 PO BOX 950 DENVER, CO 80201-095050GREATER LACROSSE HLTH .................................... 54402G001GROUP HEALTH COOP/S CTRL .............................. 53715G001GROUP HEALTH OF SPOKANE ............................... 99204G001GROUP HLTH INC ..................................................... 10036G001GROUP MGMT SERVICES INC................................. 53151G001GUARANTEE RESERVE LIFE ................................... 60409G001GUARANTEE TRUST LIFE INS ................................. 60025G001GUARDIAN LIFE ........................................................ 54913G001GULF SOUTH HEALTH PLAN ................................... 70898G001HARBOR INS CO ....................................................... 90010H001HARTFORD ACCIDENT & INDEMNI ......................... 50398H001HARTFORD INS CO ................................................... 22312H001 ATTN: PAM MORMINO PO BOX 11910 ALEXANDRIA, VA 22312-097010HARTFORD INS CO ................................................... 66201H001 PO BOX 757 SHAWNEE MISSION, KS 66201-075757HARTFORD LIFE & ACC CO ..................................... 06104H001HARVEST LIFE INS CO ............................................. 32887H001HAWKEYE NATL LIFE INS CO .................................. 50266H001HEALTH ADVANTAGE ............................................... 29501H001HEALTH BENEFIT PLAN ........................................... 08854H001HEALTH CARE ........................................................... 99016H001HEALTH CARE BENEFIT ........................................... 60685H001 CNA PLAZA CHICAGO, IL 60685HEALTH CARE BENEFIT ........................................... 29260H001 PO BOX 6927 COLUMBIA, SC 29260HEALTH FIRST PPO .................................................. 29605H001HEALTH PARTNERS OF ALABAMA ......................... 35209H001HEALTH SERVICES ASSOC ..................................... 98227H001HEALTHGUARD SERVICES INC............................... 97440H001HEALTHGUARD SERVICES OF W........................... 98227H001HEALTH & LIFE INS ................................................... 61105H001HEALTHLINK .............................................................. 63132H001HILL COUNTRY LIFE INS CO .................................... 78720H001HILL COUNTRY OF MONTANA ................................. 59771H001HLTH CARE SERVICE ............................................... 60601H001HOLY FAMILY SOCIETY OF US ............................... 60434H001

HOME BENEFICIAL LIFE INS .................................... 23261H001HUMANA CARE PLUS ............................................... 40201H002HUMANA GOLD CLAIMS ........................................... 80210H001HUMANA HLTH CARE PLANS ................................... 32245H001HUMANA REGIONAL SVCE CTR .............................. 78229H001ICI HLTH CLAIMS SERVICES ..................................... 33427I001IGG ASSOCIATION ..................................................... 68175I001IHC SENIOR CARE ..................................................... 84111I001ILLINOIS CENTRAL GULF .......................................... 48909I001INDUSTRIAL CASUALTY INS C................................. 60301I001INTEGRITY NATL LIFE INS ........................................ 40232I001INTER COUNTY HOSP PLAN INC.............................. 19044I001INTERCONTINENTAL LIFE INS .................................. 78714I001INTERGROUP PREPAID SVCS O.............................. 85710I001INTL BENEFITS SERVICES CO ................................. 76109I001INVESTORS CONSOLIDATED IN ............................... 27702I001INVESTORS DIVERSIFIED INS .................................. 70816I001INVESTORS HERITAGE LIFE I.................................. 40602I001ITT LIFE INS CORP..................................................... 55441I001J C STEELE & SONS INC ...........................................27702J001JC PENNY LIFE INS CO .............................................75221J001JEFFERSON LIFE INS CO..........................................75243J001JOINT BENEFIT TRUST..............................................94551J001KAISER GROWN HLTH PLAN................................... 20016K001KAISER PERMANENTE ............................................. 90041K001KANAWHA INS CO ..................................................... 29721K001KEYSTONE INS CO ................................................... 19103K001KING COUNTY BLUE SHIELD................................... 50398K001KING COUNTY MEDICAL .......................................... 98101K001KITSAP PHYSICIANS SRVC...................................... 98310K001KLAMATH MEDICAL .................................................. 97601K001LEGAL SECURITY LIFE INS C...................................75185L001LIBERTY LIFE INS CO ................................................29602L001LIBERTY MUTUAL INS CO .........................................90804L001LIBERTY NATL LIFE INS CO ......................................35207L001LIFE INS CO OF CONNECTICUT ...............................57193L001LIFE INS CO OF GEORGIA ........................................35289L001LIFE INS CO OF VIRGINIA .........................................19053L001LIFE INSURANCE OF VA............................................24540L001LIFE INVESTORS CO .................................................52402L001LIFE OF AMERICA ......................................................77019L001LIFE OF GEORGIA ASSOC DR ..................................35209L001LIFE OF GEORGIA INS ...............................................31999L001LIFE & HLTH INS CO OF AME....................................19103L001LINCOLN LIFE & CAS CO...........................................68501L001LINCOLN MUT LIFE & CAS IN ....................................58107L001LINCOLN NATIONAL INS ............................................21701L001LUTHERAN BROTHERHOOD INS ..............................55415L001MARICOPA MANAGED CARE SYS...........................85034M001MARITIME ASSOC .....................................................77034M001MARKET EMPLOYEES ASSOCIATIO .......................28222M001MARSH & MCCLELLAN GRP.....................................60606M002MASSACHUSETTS MUTUAL.....................................20063M002MAXICARE .................................................................28217M001MEDCENTERS SENIOR LINK ...................................55435M001MEDI PAK...................................................................77203M001MEDICAL SERV ADMIN OF MI ..................................50309M001MEDICAL SERVICE CORP ........................................99220M001MEDICAL SERVICE OF D C......................................20065M001MEDICARE-AID ..........................................................27622M001MEDICO LIFE INS CO................................................68103M001MEDICOMP ................................................................04104M001 PO BOX 9790 PORTLAND, ME 04104-509090MEDICOMP ................................................................29609M001 1300 RUTHERFORD RD GREENVILLE, SC 29609-310000MEDIPLUS ..................................................................50398M001MEMORIAL LIFE INS CO ...........................................54402M001MENNONITE MUTUAL AID ........................................46526M001METROPOLITAN LIFE INS ........................................08807M001MID AMER MUT LIFE INS CO ...................................55113M001MID SOUTH INS CO...................................................28302M001MIDAMERICA MUTUAL LIFE INS ..............................60606M001MII LIFE INCORPORATED.........................................55164M001MILICARE - FLEET RESERVE AS.............................20063M001MINNESOTA COMP HLTH ASSOC ...........................55164M002



PACIFIC MUTUAL LIFE ............................................. 98003P001 33400 8TH AVE S FEDERAL WAY, WA 98003-638200PACIFIC NORTHWEST LIFE IN ................................. 97207P001PANHANDLE EASTERN CORP ................................. 77251P001PARK & SHOP INS ..................................................... 53801P001PAUL REVERE LIFE INS CO ..................................... 01608P001PEARCE IND .............................................................. 77235P001PEHP .......................................................................... 84102P001PEIA HEALTH ECON CORP ...................................... 25362P001PEKIN LIFE INS CO ................................................... 61558P001PENINSULAR LIFE INS CO ....................................... 27605P001PENN GENERAL SVCS OF GA ................................. 30358P001PENN TREATY LIFE INS CO ..................................... 18105P001PENNSYLVANIA LIFE INS ......................................... 90406P001PEOPLES LIFE INS CO ............................................. 60008P001 PO BOX 5090 ROLLING MEADOWS, IL 60008PEOPLES LIFE INS CO ............................................. 29609P001 1300 RUTHERFORD ROAD GREENVILLE, SC 29609PEOPLES SECURITY INS ......................................... 24540P001PEOPLES SECURITY LIFE INS ................................ 27702P001PFWB BENEVOLENT ASSO ..................................... 28335P001PHILADELPHIA AMER ............................................... 19034P001PHYSICIANS HLTH PLAN.......................................... 55440P001PHYSICIANS MUTUAL INS CO .................................68131M001PIERCE COUNTY MED BUREAU.............................. 98401P001PILGRIM LIFE INS CO ............................................... 19032P001PILOT LIFE INS CO.................................................... 37220P001PIONEER LIFE INS CO .............................................. 61105P001PLAN 65 OF KANSAS ................................................ 66629P001PREFERRED ADMINISTRATIVE SE ......................... 53715P001PREFERRED BANKERS LIFE IN ............................... 75205P001PREFERRED CHOICE ............................................... 92196P001PREFERRED HLTH CARE......................................... 67214P001PREFERRED LIFE INS CO OF NY ............................ 10019P001PREFERRED RISK LIFE ............................................ 50265P001PRESIDENTIAL LIFE ................................................. 75228P001PRIME CARE PLUS ................................................... 43235P001PRIME HLTH .............................................................. 64134P001PRINCIPAL HLTH CARE ............................................ 64141P001PRINCIPAL MUTUAL INS .......................................... 55430P001PRINCIPAL MUTUAL LIFE ......................................... 68154P001PROTECTED HOME MUT LIFE I............................... 16146P001PROTECTIVE LIFE INS CO ....................................... 35202P001PROVIDENCE LIFE.................................................... 38187P001PROVIDENT CLAIM OFFICE ..................................... 37422S001PROVIDENTIAL LIFE INS CO.................................... 72203P001PROVIDERS FIDELITY LIFE I................................... 19422P001PYRAMID LIFE INS CO.............................................. 66202P001QUAL-MED INC .......................................................... 87110Q001R E HARRINGTON INC .............................................. 28226R001RAND MCNALLY ........................................................ 29609R001RELIABLE LIFE INS CO ............................................. 63119R001RESERVE NATL LIFE IN ........................................... 73118R001RHONE POULENE OF WY ........................................ 82935R001RHULEN INS CO ........................................................ 12701R001RISK MANAGEMENT INC.......................................... 93794R001RURAL SECURITY LIFE INS C.................................. 53705R001SAN ANTONIO REG CLAIM CTR .............................. 78216S001SAVERS LIFE INS CO ............................................... 27103S001SDC - SYSTEM DEVELOPMENT .............................. 73154S002SECURE CARE .......................................................... 19493S001SECURE HORIZONS HLTH PL ................................. 90630S001SECURITY GENERAL INS ......................................... 37422S001SECURITY GENERAL LIFE INS ................................ 73154S001SECURITY HLTH PLAN OF WI .................................. 54449S001SECURITY LIFE INS CO ............................................ 77019S001SECURITY NATL LIFE INS CO .................................. 84157S001SECURITY TRUST LIFE INS C.................................. 27702S001SEGUROS DE SERVICIO DE SAL ............................ 00936S001SELECTCARE ............................................................ 08221S001SENIOR CARE ........................................................... 91351S001SENIOR SECURITY LIFE INS ................................... 73154S003SENTRY LIFE INS ...................................................... 54481S001

MINNESOTA PROTECTIVE LIFE I............................68114M001MONTGOMERY WARD LIFE INS CO........................60197M001MONUMENTAL GENERAL INS CO ...........................18504M001MONY .........................................................................77006M001MOUNTAIN STATE BCBS..........................................26003M001MPS OF MICHIGAN...................................................48266M001MUTUAL BENEFIT CO ...............................................29260M001MUTUAL LIFE INS CO ...............................................20037M001 1255 23RD ST NW WASHINGTON, DC 20037-112555MUTUAL LIFE INS CO ...............................................35064M001 701 LLOYD NOLAN PKY FAIRFIELD, AL 35064-266001MUTUAL LIFE INS CO OF NY ...................................10577M001MUTUAL OF NEW YORK ...........................................10019M001MUTUAL OF OMAHA .................................................68131M001MUTUAL PROT MEDICO LIFE...................................68172M001MUTUAL SERVICE LIFE INS C.................................55164M003N CENTRAL 65 PLUS ................................................ 54402N001NATIONAL LIBERTY GROUP .................................... 19493N002NATIONWIDE LIFE INS CO ....................................... 43216N001NATL BENEFIT CORP ............................................... 64111N001NATL BENEFIT LIFE INS CO..................................... 10016N001NATL CASUALTY INS ................................................ 63101N001NATL COUNCIL SR CITIZEN ..................................... 10533N001NATL FARMERS UNION LIFE ................................... 64199N001NATL FARMERS UNION LIFE INS ............................ 80231N001NATL FINANCIAL INS CO .......................................... 75266N001NATL FOUNDATION LIFE.......................................... 76102N001NATL HEALTH INS CO .............................................. 75261N001NATL HERITAGE INS ................................................. 78720N001NATL HOME LIFE ASSUR ......................................... 13901N001 ATTN: ART KLOSE 1 MARINE MIDLAND PLZ BINGHAMTON, TX 13901-321601NATL HOME LIFE ASSUR ......................................... 19493N001 ATTN: MEDIGAP UNIT 20 MOORES RD VALLEY FORGE, PA 19493NATL LIFE .................................................................. 92049N001NATL LIFE INS CO OF TEXAS.................................. 76015N001NATL SECURITY INS CO .......................................... 17901N001NATL STATES INS ..................................................... 50306N001NATL STATES INS CO............................................... 63141N001NATL TRAVELERS LIFE ............................................ 50309N001NATL VISION .............................................................. 85060N001NAUS - UNISERVICE ................................................. 20852N001NEW YORK LIFE ........................................................ 30348N001NEW YORK LIFE INS .................................................68131M001NORTH AMER INS CO............................................... 53744N001 ATTN: KAREN TRAINER PO BOX 44160 MADISON, WI 53744-416060NORTH AMER INS CO............................................... 55440N001 4000 OLSON MEMORIAL HW PO BOX 503 MINNEAPOLIS, MN 55440-9863NORTH AMER INS CO............................................... 64111N002 ATTN: MEDIGAP UNIT BROADWAY AT 34TH ST KANSAS CITY, MO 64111NORTH ATLANTIC CAS & SURE .............................. 46206N001NORTH CAROLINA MUTUAL .................................... 37202N001NORTHWESTERN NATL LIFE................................... 56143N001NORTHWESTERN PUBLIC SERVICE ....................... 57350N001NWNL HEALTH MANAGEMENT CO ......................... 55440N001OKLAHOMA STATE INS ............................................73124O001OLD AMER INS CO ....................................................64141O001OLD SOUTHERN LIFE INS CO..................................36101O001OLD SURETY LIFE INS CO .......................................73154O001OREGON PACIFIC STATES ......................................97207O001PACIFIC HOSPITAL ASSOCIAT ................................ 97401P001PACIFIC MUTUAL LIFE.............................................. 91203P001 620 N BRAND BLVD GLENDALE, CA 91203-123920



SHELTER LIFE INS CO ............................................. 65218S001SIERRA HEALTH & LIFE INS .................................... 89114S001SKAGIT CTY MED BUREAU INC............................... 98273S001SOUTH ATLANTIC LIFE............................................. 60076S001 8255 CENTRAL PARK AVE SKOKIE, IL 60076-290855SOUTH ATLANTIC LIFE............................................. 33101S001 ONE INDEPENDENT DRIVE JACKSONVILLE, FL 33001SOUTHERN FARM BUREAU LIFE ............................ 39205S001SOUTHERN HEALTH PLAN ...................................... 38101S001SOUTHLAND LIFE INS CO ........................................ 35289S001SOUTHWEST ADMINISTRATOR .............................. 90057S001SOUTHWEST SERVICES LIFE ................................. 76118S001SOUTHWESTERN GENERAL LIFE I......................... 75266S001ST MICHAELS/PA ...................................................... 53209S001STANDARD GUARANTY INS .................................... 30327S001STANDARD LIFE INS CO ..........................................68131M001STANDARD LIFE & ACC INS C................................. 73125S001STATE FARM INS CO ................................................ 07477S001 1750 STATE RT 23 WAYNE, NJ 07477-000150STATE FARM INS CO ................................................ 22909S001 1500 STATE FARM BLVD CHARLOTTESVILLE, VA 22909-000100STATE FARM INS CO ................................................ 24319S001 PO BOX 1330 CHILHOWIE, VA 24319-133030STATE FARM INS CO ................................................ 24605S001 PO BOX 368 BLUEFIELD, VA 24605-036868STATE FARM INS CO ................................................ 28337S001 304 W BROAD ST ELIZABETHTOWN, NC 28337-939604STATE FARM INS CO ................................................ 28472S001 303 JEFFERSON ST WHITEVILLE, NC 28472-360103STATE FARM INS CO ................................................ 28645S001 226 THRIFT ST LENOIR, NC 28645STATE FARM INS CO ................................................ 30136S001 HEALTH CLAIM DEPT 11350 JOHNS CREEK PKY DULUTH, GA 30136-154150STATE FARM INS CO ................................................ 32232S001 8001 BAYMEADOWS DR JACKSONVILLE, FL 32232-5061STATE FARM INS CO ................................................ 37131S001 ATTN: MEDIGAP UNIT 2500 MEMORIAL BLVD MURFREESBORO, TN 37131-000100STATE FARM INS CO ................................................ 55161S001 1500 HIGHWAY 36 W ST. PAUL, MN 55161-000100STATE FARM INS CO ................................................ 61709S001 ATTN: LISA APPLE 2702 IRELAND GROVE RD BLOOMINGTON, IL 61709STATE FARM INS CO ................................................ 71208S001 22 STATE FARM DR MONROE, LA 71208-000222STATE FARM INS CO ................................................ 83330S001 1241 MAIN ST GOODING, ID 83330-183441STATE FARM INS CO ................................................ 97303S001 4600 25TH AVE NE SALEM, OR 97303-237100

STATE GROUP BENEFITS ........................................ 70804S001STATE MUTUAL CO .................................................. 01653S001STATES GENERAL LIFE INS .................................... 75214S001STATESMAN NATL LIFE ........................................... 77006S001STATEWIDE INS CO.................................................. 28110S001SUMMIT NATL LIFE INS CO...................................... 17601S001SURGICAL CARE ....................................................... 53201S001TAKE CARE HLTH PLAN........................................... 94524T001TEAM-CARE HEALTH CHOICE ................................. 38174T001TENNECO................................................................... 32276T001TIME ........................................................................... 53201T001TRANSAMERICA ACCIDENTAL LIF .......................... 91785T001TRANSAMERICA INS ................................................. 91367T001TRANSPORT LIFE ..................................................... 76102T001TRAVELERS INS CO ................................................. 06517T001TRAVELERS OMAHA ................................................. 68175T001TRIGON MUTUAL INS CO/ BCBS ............................. 24031B001TROA INS PLANS ...................................................... 50306T001UNDERWRITERS LIFE INS CO ................................. 75238U001UNION BANKERS INS CO ......................................... 75265U001UNION CARE LIFE INS CO........................................ 20001U001UNION FIDELITY LIFE INS ........................................ 19047U001UNION LABOR LIFE................................................... 20006U001UNION LABOR LIFE INS CO ..................................... 10010U001UNION MUTUAL LIFE INS ......................................... 19049U001UNITED AMER INS CO .............................................. 75221U001UNITED ASSURANCE CO OF PA ............................. 19047U002UNITED COMMERCIAL TRAVLRS ............................ 43215U001UNITED FAMILY LIFE INS ......................................... 30301U001UNITED FARM BUREAU FAMILY .............................. 46206U001UNITED FOUNDERS LIFE ......................................... 35202U001UNITED FOUNDERS LIFE INS .................................. 73112U001UNITED GENERAL LIFE INS C................................. 33743U001UNITED GENERAL LIFE INS CO............................... 34616U001UNITED HERITAGE MUTUAL.................................... 83653U001UNITED INVESTORS LIFE INS ................................. 75221U001UNITED LIFE OF NORTH AMER ............................... 22182U001UNITED METHODIST GROUP................................... 68175U001UNITED OF OMAHA ................................................... 19047U001UNITED SEC ASSURANCE CO O............................. 18964U001UNITED TECHNOLOGIES ......................................... 06146U001UNIVERSAL FIDELITY LIFE I.................................... 73533U001UNIVERSAL LIFE INS CO.......................................... 23222U001US GUARDIAN HEALTH INS CO............................... 75244U001USAA LIFE INS CO .................................................... 78288U001 (UNITED STATES AUTOMOBILE ASSN)USABLE LIFE ............................................................. 72203U001VALLEY HEALTH PLAN............................................. 54702V001VETERANS ADMINISTRATION ................................. 85012V001VETERANS LIFE INS CO........................................... 19493V001VFW MEDICARE SUPPLEMENT ............................... 64111V001VICTORY LIFE INS CO .............................................. 37133V001VIRGINIA HLTH & ACC ASSOC ................................ 23847V001VIRGINIA MUTUAL INS CO ....................................... 23225V001VULCAN LIFE INS CO................................................ 35201V001WALLA WALLA VALLEY MED CO ............................ 99362W001WASHINGTON NATL INS ......................................... 60201W001WC KUMMEROW & CO ............................................ 60014W001WEA INSURANCE GROUP....................................... 53708W001WESTERN FARM BUREAU INS ............................... 80217W001WESTERN FIDELITY INS ......................................... 76101W001WHATCOM MEDICAL BUREAU ............................... 98227W001WISCONSIN HLTH ORGANIZ ................................... 53212W001WISCONSIN PHYSICIANS SERVIC ......................... 53701W001WORLD INS CO ........................................................ 68130W001WORLD LIFE & HLTH INS CO .................................. 17105W001



1994 DURABLEMEDICALEQUIPMENT FEESCHEDULECORRECTIONS

Code A4253

We have revised the fee schedule for HCFA Common Procedure Coding System(HCPCS) code A4253 because the fee schedule base year data for the code wascorrupted by data for urine test strips, per 100. Formerly both urine test strips andblood glucose test strips were represented by HCPCS code A4253. Urine teststrips are now represented by HCPCS code A4250 and are not covered byMedicare.

1994 DME FEE SCHEDULES - SUPPLIES (PURCHASE NEW) FOR HCPCS CODE

HCPCS AL AR CO FL GA KY LA MS NM NC OK SC TN TX VI PR

A4253 35.31 35.31 31.85 35.31 30.76 35.31 35.31 35.31 32.35 32.45 31.92 34.32 35.31 33.72 35.31 34.69

The following fee schedule matrix is a correction to the schedule previouslypublished and was corrected as a result of some updates provided by HCFA. Thisschedule supercedes the pricing matrix for these items which was published inthe January 1994 DMERC Medicare Advisory.

1994 Nebulizer,CPAP, and SuctionPump AccessoriesCode Corrections

1994 NEBULIZER, CPAP, AND SUCTION PUMP ACCESSORIES CODE CORRECTIONSINEXPENSIVE OR ROUTINELY PURCHASED ITEMS (PURCHASED NEW)

HCPCS FL GA NC SC AL KY MS TN AR LA OK TX NM PR VI

K0168 2.28 2.37 2.35 2.39 2.41 2.39 2.41 2.41 2.41 2.41 2.40 2.28 2.40 2.73 2.40K0169 1.34 1.34 1.34 1.34 1.34 1.34 1.34 1.34 1.34 1.34 1.34 1.34 1.34 1.07 1.34K0170 23.03 23.03 23.03 23.03 23.03 23.03 23.03 23.03 23.03 23.03 23.03 23.03 23.03 17.90 24.43K0171 8.33 8.38 8.38 8.38 8.38 8.38 8.38 8.38 8.38 8.38 8.38 8.33 8.38 10.00 7.15K0172 3.65 3.79 3.75 3.82 3.89 3.82 3.86 3.92 3.86 3.98 3.83 3.65 3.83 4.37 3.49K0173 8.21 8.21 8.21 8.21 8.21 8.21 8.21 8.21 8.21 8.21 8.21 8.21 8.21 7.67 9.66K0174 34.31 35.69 35.35 36.03 36.72 36.03 36.38 36.95 36.38 36.95 36.11 34.31 36.21 41.18 33.32K0175 17.62 17.62 17.62 17.62 17.62 17.62 17.62 17.62 17.62 17.62 17.62 17.62 17.62 18.75 20.49K0177 3.16 3.30 3.28 3.33 3.33 3.33 3.33 3.33 3.33 3.33 3.33 3.16 3.33 3.80 3.14K0178 0.62 0.62 0.62 0.62 0.62 0.62 0.62 0.62 0.62 0.62 0.62 0.62 0.62 0.44 0.65K0179 3.80 3.94 3.91 3.94 3.94 3.94 3.94 3.94 3.94 3.94 3.94 3.80 3.94 4.57 3.55K0180 1.65 1.65 1.65 1.65 1.65 1.65 1.65 1.65 1.65 1.65 1.65 1.65 1.65 2.02 1.45K0181 5.73 5.94 5.89 6.00 6.13 6.00 6.07 6.17 6.07 6.23 6.02 5.73 6.04 6.86 5.73K0182 0.29 0.29 0.29 0.29 0.29 0.29 0.29 0.29 0.29 0.29 0.29 0.29 0.29 0.25 0.34K0183 67.27 69.97 69.30 70.63 70.63 70.63 70.63 70.63 70.63 70.63 70.63 67.27 70.63 80.73 63.73K0184 20.42 21.23 21.02 21.43 21.64 21.43 21.64 21.64 21.64 21.64 21.49 20.42 21.54 24.50 19.55K0185 30.49 31.72 31.42 32.01 32.63 32.01 32.32 32.85 32.32 33.24 32.09 30.49 32.17 36.59 31.12K0186 13.60 13.60 13.60 13.70 13.97 13.70 13.82 14.06 13.82 14.22 13.74 13.60 13.76 15.66 16.00K0187 33.68 35.04 34.69 35.37 36.04 35.37 35.71 36.04 35.71 36.04 35.46 33.68 35.54 40.43 34.46K0188 4.51 4.69 4.65 4.73 4.73 4.73 4.73 4.73 4.73 4.73 4.73 4.51 4.73 5.41 4.02K0189 11.45 11.45 11.45 11.45 11.45 11.45 11.45 11.45 11.45 11.53 11.45 11.45 11.45 12.68 13.47K0190 7.99 8.31 8.24 8.38 8.38 8.38 8.38 8.38 8.38 8.38 8.38 7.99 8.38 9.59 7.32K0191 24.71 25.43 25.21 25.69 26.18 25.69 25.94 26.37 25.94 26.67 25.75 24.71 25.81 29.36 26.21K0192 2.86 2.86 2.86 2.86 2.86 2.86 2.86 2.86 2.86 2.86 2.86 2.86 2.86 2.38 3.04


A4627 RR PR 78.31 A4631 NU VI 88.85A4630 PR 4.19 A4635 NU VI 4.50A4631 NU PR 113.23 A4636 NU VI 3.70A4635 NU PR 4.87 A4637 NU VI 1.58A4636 NU PR 2.09 A4640 NU VI 48.89A4637 NU PR 2.37 A5051 VI 1.98A4640 NU PR 66.89 A5052 VI 1.46A5051 PR 2.30 A5053 VI 1.45A5052 PR 1.11 A5054 VI 1.41A5053 PR 1.11 A5055 VI 1.24A5054 PR 1.21 A5061 VI 3.05A5055 PR 4.45 A5062 VI 2.28A5061 PR 3.07 A5063 VI 1.96A5062 PR 2.81 A5064 VI 3.80A5063 PR 2.09 A5065 VI 2.79A5064 PR 1.67 A5071 VI 4.10A5065 PR 1.67 A5072 VI 3.19A5071 PR 1.67 A5073 VI 2.68A5072 PR 1.67 A5074 VI 4.97A5073 PR 3.11 A5075 VI 3.60A5074 PR 8.16 A5081 VI 2.89A5075 PR 3.11 A5082 VI 8.88A5081 PR 1.34 A5093 VI 1.56A5082 PR 1.34 A5102 VI 24.31A5093 PR 1.11 A5105 VI 35.82A5102 PR 4.89 A5112 VI 26.96A5105 PR 17.79 A5113 VI 4.13A5112 PR 4.89 A5114 VI 7.85A5113 PR 5.50 A5119 VI 9.47A5114 PR 5.50 A5121 VI 5.58A5119 PR 6.40 A5122 VI 10.01A5121 PR 3.63 A5123 VI 4.24A5122 PR 12.43 A5126 VI 0.99A5123 PR 3.83 A5131 VI 13.94A5126 PR 1.57 E0100 NU VI 18.52A5131 PR 44.48 E0100 RR VI 5.23E0100 NU PR 30.15 E0100 UE VI 14.77E0100 RR PR 3.77 E0105 NU VI 43.16E0100 UE PR 22.61 E0105 RR VI 7.79E0105 NU PR 53.37 E0105 UE VI 33.28E0105 RR PR 6.66 E0110 NU VI 68.19E0105 UE PR 40.03 E0110 RR VI 11.95E0110 NU PR 87.32 E0110 UE VI 51.14E0110 RR PR 10.92 E0111 NU VI 44.52E0110 UE PR 65.49 E0111 RR VI 6.29E0111 NU PR 43.42 E0111 UE VI 33.38E0111 RR PR 5.43 E0112 NU VI 32.52E0111 UE PR 32.57 E0112 RR VI 7.41E0112 NU PR 39.37 E0112 UE VI 24.81E0112 RR PR 4.92 E0113 NU VI 18.57E0112 UE PR 29.52 E0113 RR VI 4.53E0113 NU PR 19.68 E0113 UE VI 13.94E0113 RR PR 2.46 E0114 NU VI 38.65E0113 UE PR 14.77 E0114 RR VI 6.79E0114 NU PR 54.72 E0114 UE VI 29.31E0114 RR PR 6.84 E0116 NU VI 20.72E0114 UE PR 41.05 E0116 RR VI 4.74E0116 NU PR 27.37 E0116 UE VI 15.60E0116 RR PR 3.43 E0130 NU VI 60.21E0116 UE PR 20.52 E0130 RR VI 12.57E0130 NU PR 79.90 E0130 UE VI 48.10E0130 RR PR 9.99 E0135 NU VI 73.68E0130 UE PR 69.30 E0135 RR VI 14.72E0135 NU PR 106.38 E0135 UE VI 56.53E0135 RR PR 12.76 E0141 NU VI 101.32E0135 UE PR 59.84 E0141 RR VI 16.71E0141 NU PR 128.21 E0141 UE VI 75.99E0141 RR PR 16.04 E0142 NU VI 128.47E0141 UE PR 96.17 E0142 RR VI 19.75E0142 NU PR 137.70 E0142 UE VI 97.84E0142 RR PR 17.21 E0143 NU VI 105.67E0142 UE PR 103.29 E0143 RR VI 18.99E0143 NU PR 133.80 E0143 UE VI 79.07E0143 RR PR 16.72 E0145 RR VI 18.23E0143 UE PR 100.34 E0146 RR VI 14.23

A4190 KB PR 1.28 A4190 KB VI 0.90A4190 KC PR 4.09 A4190 KC VI 5.82A4190 KD PR 9.07 A4190 KD VI 11.05A4200 KB PR 0.63 A4200 KB VI 0.34A4200 KC PR 2.14 A4200 KC VI 1.91A4200 KD PR 2.53 A4200 KD VI 2.95A4203 KF PR 1.91 A4202 KF VI 0.41A4204 PR 3.47 A4203 KF VI 1.50A4205 PR 4.09 A4204 VI 3.80A4214 PR 1.09 A4205 VI 5.31A4253 PR 34.69 A4214 VI 1.30A4256 NU PR 8.88 A4253 VI 35.31A4259 NU PR 10.50 A4256 NU VI 8.56A4310 PR 15.56 A4259 NU VI 11.20A4311 PR 9.90 A4310 VI 6.79A4312 PR 22.57 A4311 VI 11.88A4313 PR 16.40 A4312 VI 13.46A4314 PR 22.57 A4313 VI 16.28A4315 PR 22.57 A4314 VI 21.44A4316 PR 22.57 A4315 VI 23.19A4320 PR 54.37 A4316 VI 24.96A4322 PR 23.68 A4320 VI 4.30A4323 PR 6.00 A4322 VI 2.68A4326 PR 1.34 A4323 VI 6.55A4327 PR 1.11 A4326 VI 8.56A4328 PR 1.11 A4327 VI 35.44A4329 PR 22.57 A4328 VI 9.19A4330 PR 1.11 A4329 VI 30.64A4338 PR 7.49 A4330 VI 5.34A4340 PR 4.86 A4338 VI 9.53A4344 PR 23.91 A4340 VI 18.22A4346 PR 15.19 A4344 VI 14.08A4347 PR 1.34 A4346 VI 15.61A4351 PR 8.06 A4347 VI 15.20A4352 PR 8.06 A4351 VI 1.35A4354 PR 15.56 A4352 VI 5.64A4355 PR 20.79 A4354 VI 8.81A4356 PR 28.96 A4355 VI 7.83A4357 PR 8.61 A4356 VI 34.09A4358 PR 4.89 A4357 VI 8.53A4359 PR 24.45 A4358 VI 5.52A4361 PR 9.04 A4359 VI 26.77A4362 PR 3.08 A4361 VI 13.72A4363 PR 6.59 A4362 VI 3.04A4364 PR 5.78 A4363 VI 3.31A4367 PR 6.43 A4364 VI 2.58A4397 PR 6.79 A4367 VI 6.02A4398 PR 25.36 A4397 VI 3.73A4399 PR 12.51 A4398 VI 10.12A4400 PR 49.45 A4399 VI 10.43A4402 PR 2.78 A4400 VI 36.52A4404 PR 1.57 A4402 VI 1.40A4454 PR 1.04 A4404 VI 1.48A4455 PR 1.00 A4454 VI 1.95A4556 NU PR 6.22 A4455 VI 1.06A4557 NU PR 14.81 A4460 KF VI 0.89A4558 NU PR 1.71 A4556 NU VI 10.66A4560 PR 26.70 A4557 NU VI 16.75A4580 PR 51.50 A4558 NU VI 4.03A4611 NU PR 232.97 A4560 VI 16.94A4612 NU PR 28.55 A4611 NU VI 146.75A4613 NU PR 354.97 A4612 NU VI 62.64A4615 PR 2.74 A4613 NU VI 126.67A4616 PR 1.14 A4618 NU VI 7.81A4617 PR 2.74 A4620 VI 6.82A4618 NU PR 38.94 A4621 VI 4.61A4619 PR 9.59 A4622 VI 42.78A4620 PR 4.80 A4623 VI 5.76A4621 PR 5.48 A4624 VI 1.96A4622 PR 2.67 A4625 VI 6.09A4623 PR 2.67 A4626 VI 2.81A4624 PR 1.11 A4627 NU VI 19.35A4625 PR 38.92 A4627 RR VI 2.01A4626 PR 1.11 A4627 UE VI 14.49

A4630 VI 4.67

CODE MODIFIER STATE PRICE CODE MODIFIER STATE PRICE CODE MODIFIER STATE PRICE CODE MODIFIER STATE PRICE

1994 PRICING MATRIXFOR VIRGIN ISLANDSAND PUERTO RICO

The following is the 1994 Pricing Matrix for the Virgin Islands and Puerto Rico,specific to items priced by fee schedule.


E0145 RR PR 39.30 E0147 NU VI 318.50E0146 RR PR 39.86 E0147 RR VI 32.32E0147 NU PR 412.02 E0147 UE VI 241.05E0147 RR PR 51.50 E0153 NU VI 60.98E0147 UE PR 309.01 E0153 RR VI 6.36E0153 NU PR 78.47 E0153 UE VI 45.72E0153 RR PR 9.82 E0154 NU VI 55.56E0153 UE PR 58.85 E0154 RR VI 6.40E0154 NU PR 71.07 E0154 UE VI 43.03E0154 RR PR 8.89 E0155 NU VI 23.59E0154 UE PR 53.31 E0155 RR VI 2.88E0155 NU PR 39.49 E0155 UE VI 17.97E0155 RR PR 4.93 E0156 NU VI 23.23E0155 UE PR 29.62 E0156 RR VI 2.97E0156 NU PR 109.77 E0156 UE VI 17.43E0156 RR PR 13.72 E0157 NU VI 62.94E0156 UE PR 82.33 E0157 RR VI 6.70E0157 NU PR 66.82 E0157 UE VI 47.22E0157 RR PR 8.35 E0158 NU VI 24.03E0157 UE PR 50.11 E0158 RR VI 2.64E0158 NU PR 35.12 E0158 UE VI 18.15E0158 RR PR 4.39 E0160 NU VI 29.05E0158 UE PR 26.33 E0160 RR VI 3.80E0160 NU PR 5.23 E0160 UE VI 21.78E0160 RR PR 0.65 E0161 NU VI 23.04E0160 UE PR 3.92 E0161 RR VI 2.89E0161 NU PR 26.08 E0161 UE VI 17.27E0161 RR PR 3.27 E0162 NU VI 128.04E0161 UE PR 19.56 E0162 RR VI 13.43E0162 NU PR 223.97 E0162 UE VI 99.31E0162 RR PR 28.01 E0163 NU VI 96.93E0162 UE PR 167.96 E0163 RR VI 18.25E0163 NU PR 127.72 E0163 UE VI 74.74E0163 RR PR 15.98 E0164 NU VI 159.43E0163 UE PR 95.79 E0164 RR VI 23.23E0164 NU PR 218.55 E0164 UE VI 119.57E0164 RR PR 27.32 E0165 RR VI 16.33E0164 UE PR 163.91 E0166 RR VI 27.36E0165 RR PR 20.52 E0167 NU VI 10.56E0166 RR PR 38.81 E0167 RR VI 1.10E0167 NU PR 12.27 E0167 UE VI 7.95E0167 RR PR 1.52 E0175 NU VI 49.47E0167 UE PR 9.20 E0175 RR VI 4.95E0175 NU PR 61.33 E0175 UE VI 36.41E0175 RR PR 7.66 E0176 NU VI 94.14E0175 UE PR 46.00 E0176 RR VI 12.44E0176 NU PR 142.07 E0176 UE VI 69.97E0176 RR PR 17.65 E0177 NU VI 93.28E0176 UE PR 106.55 E0177 RR VI 10.67E0177 NU PR 142.07 E0177 UE VI 69.97E0177 RR PR 17.65 E0178 NU VI 106.64E0177 UE PR 106.55 E0178 RR VI 13.19E0178 NU PR 142.07 E0178 UE VI 79.98E0178 RR PR 17.65 E0179 NU VI 10.18E0178 UE PR 106.55 E0179 RR VI 1.01E0179 NU PR 40.63 E0179 UE VI 7.64E0179 RR PR 5.08 E0180 RR VI 32.50E0179 UE PR 30.48 E0181 RR VI 32.04E0180 RR PR 38.51 E0182 RR VI 19.71E0181 RR PR 37.82 E0184 NU VI 171.11E0182 RR PR 29.06 E0184 RR VI 21.59E0184 NU PR 203.17 E0184 UE VI 131.23E0184 RR PR 25.40 E0185 NU VI 281.11E0184 UE PR 152.38 E0185 RR VI 39.49E0185 NU PR 616.55 E0185 UE VI 215.75E0185 RR PR 77.06 E0186 RR VI 17.83E0185 UE PR 462.41 E0187 RR VI 20.41E0186 RR PR 42.55 E0188 NU VI 24.36E0187 RR PR 42.55 E0188 RR VI 4.65E0188 NU PR 30.46 E0188 UE VI 18.51E0188 RR PR 3.81 E0189 NU VI 50.62E0188 UE PR 22.85 E0189 RR VI 6.28E0189 NU PR 98.21 E0189 UE VI 38.26E0189 RR PR 12.28 E0191 NU VI 7.46E0189 UE PR 73.66 E0191 RR VI 0.76E0191 NU PR 11.14 E0191 UE VI 5.58E0191 RR PR 1.39 E0192 NU VI 329.25E0191 UE PR 8.35 E0192 RR VI 34.26E0192 NU PR 411.12 E0192 UE VI 244.09E0192 RR PR 51.40 E0193 RR VI 756.91E0192 UE PR 308.34 E0194 RR VI 2431.08E0193 RR PR 2293.54 E0196 RR VI 28.55E0194 RR PR 2378.40 E0197 NU VI 165.52E0196 RR PR 42.55 E0197 RR VI 22.84E0197 NU PR 103.23 E0197 UE VI 145.39

E0197 RR PR 12.91 E0198 NU VI 165.52E0197 UE PR 77.43 E0198 RR VI 17.14E0198 NU PR 511.76 E0198 UE VI 125.61E0198 RR PR 63.97 E0199 NU VI 28.17E0198 UE PR 383.82 E0199 RR VI 2.81E0199 NU PR 83.16 E0199 UE VI 21.13E0199 RR PR 10.39 E0200 NU VI 69.68E0199 UE PR 62.38 E0200 RR VI 9.45E0200 NU PR 146.33 E0200 UE VI 52.27E0200 RR PR 18.28 E0202 RR VI 55.03E0200 UE PR 109.75 E0205 NU VI 170.56E0202 RR PR 197.71 E0205 RR VI 18.76E0205 NU PR 228.57 E0205 UE VI 127.91E0205 RR PR 28.57 E0210 NU VI 24.38E0205 UE PR 171.41 E0210 RR VI 2.30E0210 NU PR 26.48 E0210 UE VI 18.28E0210 RR PR 3.32 E0215 NU VI 52.92E0210 UE PR 19.86 E0215 RR VI 5.54E0215 NU PR 95.80 E0215 UE VI 39.69E0215 RR PR 15.71 E0220 NU VI 6.32E0215 UE PR 71.85 E0220 RR VI 0.67E0220 NU PR 7.12 E0220 UE VI 4.73E0220 RR PR 0.89 E0225 NU VI 341.56E0225 NU PR 1386.69 E0225 RR VI 33.66E0225 RR PR 173.34 E0225 UE VI 256.17E0225 UE PR 1040.02 E0230 NU VI 6.33E0230 NU PR 12.15 E0230 RR VI 0.71E0230 RR PR 1.52 E0230 UE VI 4.74E0230 UE PR 9.12 E0235 RR VI 15.16E0235 RR PR 17.07 E0236 RR VI 33.83E0236 RR PR 31.05 E0237 NU VI 370.87E0237 NU PR 389.79 E0237 RR VI 41.30E0237 RR PR 48.73 E0237 UE VI 278.14E0237 UE PR 292.33 E0238 NU VI 20.20E0238 NU PR 27.41 E0238 RR VI 2.03E0238 RR PR 3.43 E0238 UE VI 14.84E0238 UE PR 20.56 E0239 NU VI 336.03E0239 NU PR 1184.60 E0239 RR VI 33.60E0239 RR PR 148.08 E0239 UE VI 252.03E0239 UE PR 888.46 E0249 NU VI 74.40E0249 NU PR 111.57 E0249 RR VI 8.18E0249 RR PR 13.95 E0249 UE VI 55.80E0249 UE PR 83.68 E0250 RR VI 73.03E0250 RR PR 115.81 E0251 RR VI 59.39E0251 RR PR 87.89 E0255 RR VI 103.25E0255 RR PR 147.37 E0256 RR VI 73.25E0256 RR PR 109.85 E0260 RR VI 147.58E0260 RR PR 217.34 E0261 RR VI 120.35E0261 RR PR 170.86 E0265 RR VI 175.68E0265 RR PR 250.97 E0266 RR VI 156.08E0266 RR PR 222.91 E0271 NU VI 165.86E0271 NU PR 303.82 E0271 RR VI 17.23E0271 RR PR 36.37 E0271 UE VI 129.57E0271 UE PR 227.87 E0272 NU VI 151.17E0272 NU PR 206.26 E0272 RR VI 15.78E0272 RR PR 25.79 E0272 UE VI 112.85E0272 UE PR 154.71 E0275 NU VI 12.28E0275 NU PR 13.70 E0275 RR VI 1.24E0275 RR PR 1.71 E0275 UE VI 9.22E0275 UE PR 10.28 E0276 NU VI 11.69E0276 NU PR 17.14 E0276 RR VI 1.38E0276 RR PR 2.14 E0276 UE VI 9.26E0276 UE PR 12.85 E0277 RR VI 729.64E0277 RR PR 858.95 E0280 NU VI 33.57E0280 NU PR 55.55 E0280 RR VI 3.61E0280 RR PR 6.94 E0280 UE VI 25.19E0280 UE PR 41.66 E0290 RR VI 64.72E0290 RR PR 87.70 E0291 RR VI 47.71E0291 RR PR 63.37 E0292 RR VI 73.86E0292 RR PR 115.22 E0293 RR VI 62.86E0293 RR PR 96.61 E0294 RR VI 114.85E0294 RR PR 176.20 E0295 RR VI 111.91E0295 RR PR 83.37 E0296 RR VI 144.30E0296 RR PR 192.26 E0297 RR VI 123.65E0297 RR PR 167.82 E0305 RR VI 13.27E0305 RR PR 8.81 E0310 NU VI 145.03E0310 NU PR 172.73 E0310 RR VI 17.00E0310 RR PR 21.60 E0310 UE VI 109.74E0310 UE PR 129.54 E0325 NU VI 7.56E0325 NU PR 9.86 E0325 RR VI 1.13E0325 RR PR 1.24 E0325 UE VI 5.00E0325 UE PR 7.40 E0326 NU VI 8.40E0326 NU PR 6.96 E0326 RR VI 0.89E0326 RR PR 0.88 E0326 UE VI 6.29E0326 UE PR 5.22 E0424 RR VI 301.18



E0424 RR PR 383.45 E0425 RR VI 308.12E0425 RR PR 383.45 E0430 RR VI 47.32E0430 RR PR 48.23 E0431 RR VI 47.32E0431 RR PR 48.23 E0434 RR VI 47.32E0434 RR PR 48.23 E0435 RR VI 47.32E0435 RR PR 48.23 E0439 RR VI 301.18E0439 RR PR 383.45 E0440 RR VI 308.12E0440 RR PR 383.45 E0441 VI 214.53E0441 PR 181.02 E0442 VI 214.53E0442 PR 181.02 E0443 VI 28.19E0443 PR 50.94 E0444 VI 28.19E0444 PR 50.94 E0450 RR VI 838.87E0450 RR PR 1394.75 E0452 RR VI 225.50E0452 RR PR 96.56 E0453 RR VI 564.38E0453 RR PR 655.87 E0457 RR VI 51.31E0457 RR PR 57.10 E0459 RR VI 44.72E0459 RR PR 47.75 E0460 RR VI 548.00E0460 RR PR 1123.05 E0462 RR VI 217.69E0462 RR PR 171.62 E0480 RR VI 32.82E0480 RR PR 38.73 E0500 RR VI 96.47E0500 RR PR 84.51 E0550 RR VI 44.05E0550 RR PR 72.80 E0560 NU VI 150.73E0555 NU PR 28.55 E0560 RR VI 17.67E0560 NU PR 161.18 E0560 UE VI 113.05E0560 RR PR 20.15 E0565 RR VI 53.62E0560 UE PR 120.90 E0570 RR VI 17.35E0565 RR PR 26.35 E0575 RR VI 90.32E0570 RR PR 39.29 E0585 RR VI 30.82E0575 RR PR 248.29 E0600 RR VI 40.24E0580 NU PR 131.33 E0601 RR VI 98.18E0580 RR PR 131.33 E0605 NU VI 23.23E0585 RR PR 42.72 E0605 RR VI 2.70E0600 RR PR 37.89 E0605 UE VI 19.12E0601 RR PR 103.15 E0606 RR VI 18.41E0605 NU PR 13.83 E0607 NU VI 185.79E0605 RR PR 1.73 E0607 RR VI 21.69E0605 UE PR 10.37 E0607 UE VI 144.53E0606 RR PR 19.48 E0608 RR VI 246.38E0607 NU PR 314.05 E0609 NU VI 483.81E0607 RR PR 38.26 E0609 RR VI 56.53E0607 UE PR 235.53 E0609 UE VI 395.78E0608 RR PR 304.98 E0610 NU VI 209.04E0609 NU PR 668.95 E0610 RR VI 22.05E0609 RR PR 83.62 E0610 UE VI 156.80E0609 UE PR 501.72 E0615 NU VI 384.19E0610 NU PR 444.57 E0615 RR VI 43.70E0610 RR PR 55.57 E0615 UE VI 284.99E0610 UE PR 333.43 E0621 NU VI 71.71E0615 NU PR 444.57 E0621 RR VI 6.95E0615 RR PR 55.57 E0621 UE VI 54.05E0615 UE PR 333.42 E0627 NU VI 289.15E0621 NU PR 82.14 E0627 RR VI 28.91E0621 RR PR 10.27 E0627 UE VI 216.87E0621 UE PR 61.60 E0628 NU VI 289.15E0627 NU PR 348.76 E0628 RR VI 28.91E0627 RR PR 43.60 E0628 UE VI 216.87E0627 UE PR 261.58 E0629 NU VI 247.04E0628 NU PR 348.76 E0629 RR VI 24.71E0628 RR PR 43.59 E0629 UE VI 185.27E0628 UE PR 261.58 E0630 RR VI 89.53E0629 NU PR 348.76 E0635 RR VI 100.81E0629 RR PR 43.59 E0650 NU VI 572.34E0629 UE PR 261.58 E0650 RR VI 68.78E0630 RR PR 86.49 E0650 UE VI 432.04E0635 RR PR 182.42 E0651 NU VI 686.09E0650 NU PR 613.21 E0651 RR VI 77.09E0650 RR PR 76.65 E0651 UE VI 514.56E0650 UE PR 76.65 E0652 NU VI 4420.49E0651 NU PR 829.23 E0652 RR VI 442.03E0651 RR PR 103.66 E0652 UE VI 3145.27E0651 UE PR 621.93 E0655 NU VI 85.84E0652 NU PR 5563.65 E0655 RR VI 11.14E0652 RR PR 695.46 E0655 UE VI 64.36E0652 UE PR 4172.75 E0660 NU VI 139.77E0655 NU PR 83.96 E0660 RR VI 14.07E0655 RR PR 10.45 E0660 UE VI 105.29E0655 UE PR 62.37 E0665 NU VI 120.40E0660 NU PR 153.31 E0665 RR VI 12.15E0660 RR PR 19.16 E0665 UE VI 90.42E0660 UE PR 114.98 E0666 NU VI 116.40E0665 NU PR 118.46 E0666 RR VI 11.39E0665 RR PR 14.81 E0666 UE VI 90.15E0665 UE PR 88.85 E0667 NU VI 284.55E0666 NU PR 110.10 E0667 RR VI 32.13E0666 RR PR 13.76 E0667 UE VI 213.41

E0666 UE PR 82.58 E0668 NU VI 330.10E0667 NU PR 383.26 E0668 RR VI 32.58E0667 RR PR 47.91 E0668 UE VI 247.57E0667 UE PR 287.44 E0690 NU VI 1197.68E0668 NU PR 329.91 E0690 RR VI 123.69E0668 RR PR 36.60 E0690 UE VI 896.14E0668 UE PR 274.24 E0720 NU VI 297.96E0690 NU PR 679.75 E0720 RR VI 29.80E0690 RR PR 84.96 E0720 UE VI 319.71E0690 UE PR 509.82 E0730 NU VI 299.05E0720 NU PR 409.69 E0730 RR VI 29.91E0720 RR PR 40.97 E0730 UE VI 334.26E0720 UE PR 307.27 E0731 NU VI 266.45E0730 NU PR 670.76 E0744 RR VI 80.48E0730 RR PR 67.07 E0745 RR VI 78.01E0730 UE PR 503.07 E0747 NU VI 3080.55E0744 RR PR 117.84 E0747 RR VI 308.05E0745 RR PR 80.24 E0747 UE VI 2303.17E0747 NU PR 3018.59 E0749 RR VI 200.96E0747 RR PR 445.65 E0776 NU VI 106.94E0747 UE PR 601.71 E0776 RR VI 13.94E0749 RR PR 386.54 E0776 UE VI 78.68E0776 NU PR 126.82 E0781 RR VI 235.28E0776 RR PR 15.84 E0782 NU VI 3398.58E0776 UE PR 95.13 E0782 RR VI 339.86E0781 RR PR 154.45 E0782 UE VI 2548.94E0782 NU PR 330.36 E0791 RR VI 236.22E0782 RR PR 41.30 E0840 NU VI 64.40E0782 UE PR 247.78 E0840 RR VI 14.34E0791 RR PR 173.94 E0840 UE VI 48.27E0840 NU PR 102.77 E0850 NU VI 92.33E0840 RR PR 28.55 E0850 RR VI 12.68E0840 UE PR 77.09 E0850 UE VI 69.25E0850 NU PR 100.91 E0860 NU VI 28.78E0850 RR PR 12.61 E0860 RR VI 4.86E0850 UE PR 75.67 E0860 UE VI 22.15E0860 NU PR 24.13 E0870 NU VI 102.22E0860 RR PR 3.02 E0870 RR VI 11.78E0860 UE PR 18.12 E0870 UE VI 77.00E0870 NU PR 133.32 E0880 NU VI 93.78E0870 RR PR 16.67 E0880 RR VI 14.73E0870 UE PR 99.99 E0880 UE VI 70.98E0880 NU PR 122.95 E0890 NU VI 105.82E0880 RR PR 15.38 E0890 RR VI 28.85E0880 UE PR 92.22 E0890 UE VI 85.24E0890 NU PR 97.00 E0900 NU VI 110.88E0890 RR PR 12.12 E0900 RR VI 20.63E0890 UE PR 72.75 E0900 UE VI 83.05E0900 NU PR 107.23 E0910 RR VI 17.58E0900 RR PR 13.40 E0920 RR VI 40.56E0900 UE PR 80.43 E0930 RR VI 35.55E0910 RR PR 16.76 E0935 RR VI 436.81E0920 RR PR 56.05 E0940 RR VI 30.56E0930 RR PR 41.48 E0941 RR VI 38.17E0935 RR PR 446.56 E0942 NU VI 14.82E0940 RR PR 32.87 E0942 RR VI 1.75E0941 RR PR 40.48 E0942 UE VI 11.11E0942 NU PR 3.88 E0943 NU VI 22.08E0942 RR PR 0.48 E0943 RR VI 2.42E0942 UE PR 2.90 E0943 UE VI 16.56E0943 NU PR 30.70 E0944 NU VI 34.27E0943 RR PR 3.84 E0944 RR VI 3.44E0943 UE PR 23.03 E0944 UE VI 25.70E0944 NU PR 48.77 E0945 NU VI 33.12E0944 RR PR 6.10 E0945 RR VI 3.31E0944 UE PR 36.59 E0945 UE VI 25.64E0945 NU PR 40.43 E0946 RR VI 47.04E0945 RR PR 5.06 E0947 NU VI 532.99E0945 UE PR 30.32 E0947 RR VI 55.28E0946 RR PR 54.90 E0947 UE VI 399.74E0947 NU PR 688.63 E0948 NU VI 515.53E0947 RR PR 86.08 E0948 RR VI 51.54E0947 UE PR 516.47 E0948 UE VI 363.58E0948 NU PR 686.37 E0950 NU VI 77.66E0948 RR PR 85.79 E0950 RR VI 7.78E0948 UE PR 514.78 E0950 UE VI 58.24E0950 NU PR 100.34 E0951 NU VI 16.56E0950 RR PR 12.55 E0951 RR VI 1.72E0950 UE PR 75.26 E0951 UE VI 12.42E0951 NU PR 18.35 E0952 NU VI 16.56E0951 RR PR 2.30 E0952 RR VI 1.73E0951 UE PR 13.76 E0952 UE VI 12.42E0952 NU PR 18.35 E0953 NU VI 32.75E0952 RR PR 2.30 E0953 RR VI 3.29E0952 UE PR 13.76 E0953 UE VI 24.58



E0953 NU PR 43.74 E0954 NU VI 36.77E0953 UE PR 32.81 E0954 RR VI 4.15E0954 NU PR 35.76 E0954 UE VI 27.58E0954 RR PR 4.48 E0958 RR VI 38.10E0954 UE PR 26.82 E0959 NU VI 75.51E0958 RR PR 47.29 E0959 RR VI 7.50E0959 NU PR 91.99 E0959 UE VI 58.81E0959 RR PR 11.51 E0961 NU VI 22.23E0959 UE PR 68.99 E0961 RR VI 2.32E0961 NU PR 17.41 E0961 UE VI 16.68E0961 RR PR 2.17 E0962 NU VI 52.27E0961 UE PR 13.06 E0962 RR VI 5.23E0962 NU PR 51.93 E0962 UE VI 39.20E0962 RR PR 6.49 E0963 NU VI 62.45E0962 UE PR 38.95 E0963 RR VI 6.34E0963 NU PR 58.43 E0963 UE VI 45.92E0963 RR PR 7.31 E0964 NU VI 59.23E0963 UE PR 43.83 E0964 RR VI 6.73E0964 NU PR 85.71 E0964 UE VI 44.63E0964 RR PR 10.71 E0965 NU VI 66.30E0964 UE PR 64.28 E0965 RR VI 7.46E0965 NU PR 91.99 E0965 UE VI 51.02E0965 RR PR 11.51 E0966 NU VI 62.72E0965 UE PR 68.99 E0966 RR VI 6.19E0966 NU PR 75.72 E0966 UE VI 47.03E0966 RR PR 9.48 E0967 NU VI 116.13E0966 UE PR 56.79 E0967 RR VI 11.91E0967 NU PR 126.36 E0967 UE VI 87.11E0967 RR PR 15.79 E0968 RR VI 15.74E0967 UE PR 94.77 E0969 NU VI 129.40E0968 RR PR 19.34 E0969 RR VI 13.63E0969 NU PR 177.70 E0969 UE VI 101.36E0969 RR PR 22.22 E0970 NU VI 35.98E0969 UE PR 133.27 E0970 RR VI 3.31E0970 NU PR 60.63 E0970 UE VI 26.99E0970 RR PR 7.58 E0971 NU VI 57.78E0970 UE PR 45.47 E0971 RR VI 5.58E0971 NU PR 91.35 E0971 UE VI 43.34E0971 RR PR 11.56 E0972 NU VI 46.24E0971 UE PR 69.33 E0972 RR VI 4.73E0972 NU PR 53.88 E0972 UE VI 35.47E0972 RR PR 6.75 E0973 NU VI 89.81E0972 UE PR 40.41 E0973 RR VI 8.64E0973 NU PR 99.89 E0973 UE VI 75.79E0973 RR PR 12.47 E0974 NU VI 63.76E0973 UE PR 74.91 E0974 RR VI 6.60E0974 NU PR 90.59 E0974 UE VI 49.62E0974 RR PR 11.33 E0975 NU VI 42.66E0974 UE PR 67.94 E0975 RR VI 4.26E0975 NU PR 43.89 E0975 UE VI 32.00E0975 RR PR 5.48 E0976 NU VI 37.52E0975 UE PR 32.93 E0976 RR VI 3.70E0976 NU PR 43.89 E0976 UE VI 28.13E0976 RR PR 5.48 E0977 NU VI 57.48E0976 UE PR 32.93 E0977 RR VI 5.54E0977 NU PR 47.85 E0977 UE VI 43.12E0977 RR PR 5.98 E0978 NU VI 39.13E0977 UE PR 35.90 E0978 RR VI 3.91E0978 NU PR 51.56 E0978 UE VI 29.37E0978 RR PR 6.45 E0979 NU VI 29.69E0978 UE PR 38.67 E0979 RR VI 2.98E0979 NU PR 39.02 E0979 UE VI 22.27E0979 RR PR 4.88 E0980 NU VI 24.69E0979 UE PR 29.26 E0980 RR VI 2.46E0980 NU PR 29.96 E0980 UE VI 18.42E0980 RR PR 3.75 E0990 NU VI 103.21E0980 UE PR 22.48 E0990 RR VI 10.74E0990 NU PR 159.86 E0990 UE VI 80.63E0990 RR PR 19.98 E0991 NU VI 34.27E0990 UE PR 119.88 E0991 RR VI 3.35E0991 NU PR 35.12 E0991 UE VI 25.84E0991 RR PR 4.39 E0992 NU VI 71.08E0991 UE PR 26.33 E0992 RR VI 7.09E0992 NU PR 102.98 E0992 UE VI 53.31E0992 RR PR 12.88 E0993 NU VI 34.73E0992 UE PR 77.24 E0993 RR VI 3.46E0993 NU PR 35.12 E0993 UE VI 26.16E0993 RR PR 4.39 E0994 NU VI 13.17E0993 UE PR 26.33 E0994 RR VI 1.33E0994 NU PR 10.73 E0994 UE VI 9.89E0994 RR PR 1.35 E0995 NU VI 22.71E0994 UE PR 8.04 E0995 RR VI 2.28E0995 NU PR 42.09 E0995 UE VI 17.02E0995 RR PR 5.26 E0996 NU VI 21.70E0995 UE PR 42.97 E0996 RR VI 2.16

E0996 NU PR 31.22 E0996 UE VI 16.29E0996 RR PR 3.90 E0997 NU VI 50.47E0996 UE PR 23.41 E0997 RR VI 5.32E0997 NU PR 78.47 E0997 UE VI 37.84E0997 RR PR 9.82 E0998 NU VI 30.30E0997 UE PR 58.85 E0998 RR VI 3.03E0998 NU PR 87.14 E0998 UE VI 22.72E0998 RR PR 10.90 E0999 NU VI 101.03E0998 UE PR 65.35 E0999 RR VI 9.88E0999 NU PR 110.79 E0999 UE VI 75.79E0999 RR PR 13.85 E1000 NU VI 26.89E0999 UE PR 83.10 E1000 RR VI 2.96E1000 NU PR 33.17 E1000 UE VI 20.17E1000 RR PR 4.15 E1001 NU VI 75.49E1000 UE PR 24.90 E1001 RR VI 7.68E1001 NU PR 108.29 E1001 UE VI 56.61E1001 UE PR 81.22 E1031 RR VI 37.73E1031 RR PR 30.19 E1050 RR VI 89.24E1050 RR PR 101.53 E1060 RR VI 96.92E1060 RR PR 118.14 E1065 NU VI 2540.95E1065 NU PR 2941.31 E1065 RR VI 232.28E1065 RR PR 367.66 E1065 UE VI 1905.71E1065 UE PR 2205.98 E1066 NU VI 226.98E1066 NU PR 354.97 E1066 RR VI 22.70E1066 RR PR 44.37 E1066 UE VI 173.77E1066 UE PR 266.23 E1069 NU VI 98.73E1069 NU PR 85.01 E1069 RR VI 9.92E1069 RR PR 10.62 E1069 UE VI 74.05E1069 UE PR 63.76 E1070 RR VI 91.37E1070 RR PR 217.40 E1083 RR VI 69.21E1083 RR PR 72.19 E1084 RR VI 81.01E1084 RR PR 91.49 E1085 RR VI 55.87E1085 RR PR 60.45 E1086 RR VI 73.86E1086 RR PR 79.77 E1087 RR VI 111.18E1087 RR PR 152.11 E1088 RR VI 132.51E1088 RR PR 183.00 E1089 RR VI 105.41E1089 RR PR 132.88 E1090 RR VI 119.67E1090 RR PR 163.77 E1091 RR VI 73.27E1091 RR PR 110.74 E1092 RR VI 112.94E1092 RR PR 149.96 E1093 RR VI 97.13E1093 RR PR 137.61 E1100 RR VI 85.68E1100 RR PR 112.72 E1110 RR VI 84.86E1110 RR PR 93.83 E1130 RR VI 38.91E1130 RR PR 57.73 E1140 RR VI 61.56E1140 RR PR 80.29 E1150 RR VI 71.71E1150 RR PR 90.04 E1160 RR VI 54.93E1160 RR PR 69.44 E1170 RR VI 72.60E1170 RR PR 129.97 E1171 RR VI 67.40E1171 RR PR 103.75 E1172 RR VI 86.08E1172 RR PR 97.42 E1180 RR VI 89.06E1180 RR PR 107.17 E1190 RR VI 102.90E1190 RR PR 134.11 E1195 RR VI 110.41E1195 RR PR 195.25 E1200 RR VI 76.48E1200 RR PR 110.74 E1210 NU VI 3069.30E1210 NU PR 3864.00 E1210 RR VI 306.93E1210 RR PR 386.40 E1210 UE VI 2301.98E1210 UE PR 2898.00 E1211 NU VI 3537.90E1211 NU PR 3864.00 E1211 RR VI 353.79E1211 RR PR 386.40 E1211 UE VI 2653.43E1211 UE PR 2898.00 E1212 NU VI 3030.10E1212 NU PR 3671.80 E1212 RR VI 303.01E1212 RR PR 367.18 E1212 UE VI 2272.58E1212 UE PR 2753.85 E1213 NU VI 3258.70E1213 NU PR 3741.70 E1213 RR VI 325.87E1213 RR PR 374.17 E1213 UE VI 2444.03E1213 UE PR 2806.28 E1230 NU VI 1987.79E1230 NU PR 2362.25 E1230 RR VI 195.50E1230 RR PR 295.28 E1230 UE VI 1572.11E1230 UE PR 1771.68 E1240 RR VI 82.96E1240 RR PR 97.09 E1250 RR VI 56.78E1250 RR PR 65.55 E1260 RR VI 76.07E1260 RR PR 85.33 E1270 RR VI 61.84E1270 RR PR 76.54 E1280 RR VI 115.36E1280 RR PR 182.42 E1285 RR VI 99.84E1285 RR PR 111.02 E1290 RR VI 109.99E1290 RR PR 170.19 E1295 RR VI 106.74E1295 RR PR 151.52 E1296 NU VI 367.29E1296 NU PR 452.94 E1296 RR VI 37.31E1296 RR PR 56.61 E1296 UE VI 275.47E1296 UE PR 339.70 E1297 NU VI 78.14E1297 NU PR 102.67 E1297 RR VI 8.68E1297 RR PR 12.83 E1297 UE VI 58.61E1297 UE PR 77.00 E1298 NU VI 325.70E1298 NU PR 348.42 E1298 RR VI 32.57E1298 RR PR 43.55 E1298 UE VI 244.27



E1298 UE PR 261.32 E1310 NU VI 1887.25E1310 NU PR 2236.73 E1310 RR VI 153.89E1310 RR PR 279.58 E1310 UE VI 1415.44E1310 UE PR 1677.55 E1372 NU VI 143.28E1355 NU PR 77.81 E1372 RR VI 17.69E1372 NU PR 153.48 E1372 UE VI 106.06E1372 RR PR 19.19 E1375 NU VI 170.41E1372 UE PR 115.11 E1375 RR VI 31.17E1375 NU PR 211.49 E1375 UE VI 129.56E1375 RR PR 26.44 E1400 RR VI 301.18E1375 UE PR 158.62 E1401 RR VI 301.18E1400 RR PR 383.45 E1402 RR VI 301.18E1401 RR PR 383.45 E1403 RR VI 301.18E1402 RR PR 383.45 E1404 RR VI 301.18E1403 RR PR 383.45 E1405 RR VI 332.00E1404 RR PR 383.45 E1406 RR VI 318.53E1405 RR PR 426.17 E1700 NU VI 303.06E1406 RR PR 422.74 E1700 RR VI 29.73E1700 NU PR 384.37 E1700 UE VI 227.30E1700 RR PR 48.04 E1701 NU VI 9.32E1700 UE PR 288.29 E1701 RR VI 0.93E1701 NU PR 10.02 E1701 UE VI 7.00E1702 NU PR 25.18 E1702 NU VI 19.82K0001 RR PR 64.42 E1702 RR VI 1.99K0002 RR PR 77.17 E1702 UE VI 14.85K0003 RR PR 79.81 K0001 RR VI 46.31K0004 RR PR 160.65 K0002 RR VI 69.03K0005 NU PR 1630.70 K0003 RR VI 71.87K0005 RR PR 163.07 K0004 RR VI 112.58K0005 UE PR 1223.03 K0005 NU VI 1624.78K0006 RR PR 155.45 K0005 RR VI 162.47K0007 RR PR 186.50 K0005 UE VI 1218.58K0010 NU PR 3730.40 K0006 RR VI 101.53K0010 RR PR 373.04 K0007 RR VI 154.21K0010 UE PR 2797.80 K0010 NU VI 3014.40K0011 NU PR 6101.80 K0010 RR VI 301.44K0011 RR PR 610.18 K0010 UE VI 2260.80K0011 UE PR 4576.35 K0011 NU VI 5045.50K0012 NU PR 2927.40 K0011 RR VI 504.55K0012 RR PR 292.74 K0011 UE VI 3784.13K0012 UE PR 2195.55 K0012 NU VI 2420.50K0015 NU PR 191.63 K0012 RR VI 242.05K0015 RR PR 19.16 K0012 UE VI 1815.38K0015 UE PR 143.73 K0015 NU VI 159.69K0016 NU PR 99.79 K0015 RR VI 15.98K0016 RR PR 12.47 K0015 UE VI 119.77K0016 UE PR 74.91 K0016 NU VI 89.81K0017 NU PR 53.89 K0016 RR VI 8.64K0017 RR PR 5.39 K0016 UE VI 75.79K0017 UE PR 40.42 K0017 NU VI 44.92K0018 NU PR 30.12 K0017 RR VI 4.49K0018 RR PR 3.02 K0017 UE VI 33.68K0018 UE PR 22.59 K0018 NU VI 25.09K0019 NU PR 17.24 K0018 RR VI 2.50K0019 RR PR 1.72 K0018 UE VI 18.83K0019 UE PR 12.94 K0019 NU VI 14.37K0020 NU PR 48.99 K0019 RR VI 1.44K0020 RR PR 4.90 K0019 UE VI 10.77K0020 UE PR 36.75 K0020 NU VI 40.82K0021 NU PR 91.35 K0020 RR VI 4.09K0021 RR PR 11.56 K0020 UE VI 30.61K0021 UE PR 69.33 K0021 NU VI 57.78K0022 NU PR 43.89 K0021 RR VI 5.67K0022 RR PR 5.48 K0021 UE VI 43.34K0022 UE PR 32.93 K0022 NU VI 37.52K0023 NU PR 94.52 K0022 RR VI 3.73K0023 RR PR 9.46 K0022 UE VI 28.13K0023 UE PR 70.89 K0023 NU VI 73.13K0024 NU PR 111.88 K0023 RR VI 7.31K0024 RR PR 11.20 K0023 UE VI 54.85K0024 UE PR 83.91 K0024 NU VI 86.97K0025 NU PR 75.72 K0024 RR VI 8.69K0025 RR PR 9.48 K0024 UE VI 65.22K0025 UE PR 56.79 K0025 NU VI 62.72K0026 NU PR 35.12 K0025 RR VI 6.19K0026 RR PR 4.39 K0025 UE VI 47.03K0026 UE PR 26.33 K0026 NU VI 34.73K0027 NU PR 35.12 K0026 RR VI 3.46K0027 RR PR 4.39 K0026 UE VI 26.16K0027 UE PR 26.33 K0027 NU VI 34.73K0028 NU PR 612.52 K0027 RR VI 3.46K0028 RR PR 76.57 K0027 UE VI 26.16K0028 UE PR 459.38 K0028 NU VI 479.53K0029 NU PR 43.89 K0028 RR VI 49.36K0029 RR PR 5.48 K0028 UE VI 359.63

K0029 UE PR 32.93 K0029 NU VI 42.66K0030 NU PR 215.46 K0029 RR VI 4.26K0030 RR PR 26.92 K0029 UE VI 32.01K0030 UE PR 161.60 K0030 NU VI 71.08K0031 NU PR 48.93 K0030 RR VI 7.09K0031 RR PR 6.09 K0030 UE VI 53.31K0031 UE PR 36.69 K0031 NU VI 37.53K0032 NU PR 35.12 K0031 RR VI 3.76K0032 RR PR 4.39 K0031 UE VI 27.82K0032 UE PR 26.33 K0032 NU VI 34.27K0033 NU PR 35.12 K0032 RR VI 3.36K0033 RR PR 4.39 K0032 UE VI 25.84K0033 UE PR 26.33 K0033 NU VI 34.27K0034 NU PR 18.35 K0033 RR VI 3.36K0034 RR PR 2.30 K0033 UE VI 25.84K0034 UE PR 13.76 K0034 NU VI 16.56K0035 NU PR 26.29 K0034 RR VI 1.72K0035 RR PR 2.63 K0034 UE VI 12.42K0035 UE PR 19.72 K0035 NU VI 22.77K0036 NU PR 18.35 K0035 RR VI 2.28K0036 RR PR 2.30 K0035 UE VI 17.08K0036 UE PR 13.76 K0036 NU VI 16.56K0037 NU PR 60.63 K0036 RR VI 1.73K0037 RR PR 7.58 K0036 UE VI 12.42K0037 UE PR 45.47 K0037 NU VI 35.98K0038 NU PR 25.60 K0037 RR VI 3.31K0038 RR PR 2.55 K0037 UE VI 26.99K0038 UE PR 19.20 K0038 NU VI 21.32K0039 NU PR 56.84 K0038 RR VI 2.13K0039 RR PR 5.69 K0038 UE VI 16.00K0039 UE PR 42.63 K0039 NU VI 47.35K0040 NU PR 78.74 K0039 RR VI 4.74K0040 RR PR 7.88 K0039 UE VI 35.51K0040 UE PR 59.05 K0040 NU VI 65.62K0041 NU PR 55.82 K0040 RR VI 6.56K0041 RR PR 5.58 K0040 UE VI 49.21K0041 UE PR 41.87 K0041 NU VI 46.51K0042 NU PR 60.63 K0041 RR VI 4.66K0042 RR PR 7.58 K0041 UE VI 34.89K0042 UE PR 45.47 K0042 NU VI 32.01K0043 NU PR 20.59 K0042 RR VI 3.19K0043 RR PR 2.06 K0042 UE VI 24.01K0043 UE PR 15.44 K0043 NU VI 17.16K0044 NU PR 17.54 K0043 RR VI 1.72K0044 RR PR 1.76 K0043 UE VI 12.88K0044 UE PR 13.15 K0044 NU VI 14.62K0045 NU PR 59.71 K0044 RR VI 1.46K0045 RR PR 5.97 K0044 UE VI 10.97K0045 UE PR 44.78 K0045 NU VI 49.76K0046 NU PR 20.59 K0045 RR VI 4.99K0046 RR PR 2.06 K0045 UE VI 37.33K0046 UE PR 15.44 K0046 NU VI 17.16K0047 NU PR 80.65 K0046 RR VI 1.72K0047 RR PR 8.06 K0046 UE VI 12.88K0047 UE PR 60.49 K0047 NU VI 67.21K0048 NU PR 159.86 K0047 RR VI 6.74K0048 RR PR 19.98 K0047 UE VI 50.40K0048 UE PR 119.88 K0048 NU VI 103.21K0049 NU PR 42.09 K0048 RR VI 10.74K0049 RR PR 5.26 K0048 UE VI 80.63K0049 UE PR 42.97 K0049 NU VI 22.71K0050 NU PR 34.28 K0049 RR VI 2.28K0050 RR PR 3.43 K0049 UE VI 17.02K0050 UE PR 25.72 K0050 NU VI 28.57K0051 NU PR 55.47 K0050 RR VI 2.85K0051 RR PR 5.55 K0050 UE VI 21.43K0051 UE PR 41.60 K0051 NU VI 46.23K0052 NU PR 97.49 K0051 RR VI 4.64K0052 RR PR 9.75 K0051 UE VI 34.66K0052 UE PR 73.12 K0052 NU VI 81.24K0053 NU PR 107.58 K0052 RR VI 8.12K0053 RR PR 10.75 K0052 UE VI 60.93K0053 UE PR 80.69 K0053 NU VI 89.65K0054 NU PR 110.34 K0053 RR VI 8.96K0054 RR PR 11.03 K0053 UE VI 67.24K0054 UE PR 82.76 K0054 NU VI 91.96K0055 NU PR 100.30 K0054 RR VI 9.20K0055 RR PR 10.02 K0054 UE VI 68.97K0055 UE PR 75.22 K0055 NU VI 83.58K0056 NU PR 100.30 K0055 RR VI 8.35K0056 RR PR 10.02 K0055 UE VI 62.69K0056 UE PR 75.22 K0056 NU VI 83.58K0057 NU PR 130.96 K0056 RR VI 8.35K0057 RR PR 13.10 K0056 UE VI 62.69K0057 UE PR 98.22 K0057 NU VI 109.15



K0058 NU PR 63.65 K0057 RR VI 10.92K0058 RR PR 6.37 K0057 UE VI 81.85K0058 UE PR 47.74 K0058 NU VI 53.05K0059 NU PR 33.44 K0058 RR VI 5.31K0059 RR PR 3.35 K0058 UE VI 39.79K0059 UE PR 25.09 K0059 NU VI 27.87K0060 NU PR 29.27 K0059 RR VI 2.78K0060 RR PR 2.93 K0059 UE VI 20.91K0060 UE PR 21.95 K0060 NU VI 24.39K0061 NU PR 41.52 K0060 RR VI 2.44K0061 RR PR 4.16 K0060 UE VI 18.28K0061 UE PR 31.14 K0061 NU VI 34.59K0062 NU PR 64.32 K0061 RR VI 3.46K0062 RR PR 6.43 K0061 UE VI 25.95K0062 UE PR 48.25 K0062 NU VI 53.60K0063 NU PR 85.89 K0062 RR VI 5.36K0063 RR PR 8.59 K0062 UE VI 40.20K0063 UE PR 64.42 K0063 NU VI 71.59K0064 NU PR 32.05 K0063 RR VI 7.16K0064 RR PR 3.21 K0063 UE VI 53.68K0064 UE PR 24.04 K0064 NU VI 26.72K0065 NU PR 46.88 K0064 RR VI 2.68K0065 RR PR 4.70 K0064 UE VI 20.02K0065 UE PR 35.16 K0065 NU VI 39.07K0066 NU PR 31.22 K0065 RR VI 3.90K0066 RR PR 3.90 K0065 UE VI 29.30K0066 UE PR 42.97 K0066 NU VI 21.70K0067 NU PR 43.74 K0066 RR VI 2.16K0068 NU PR 6.20 K0066 UE VI 16.29K0068 RR PR 0.62 K0067 NU VI 32.75K0068 UE PR 4.65 K0067 RR VI 3.29K0069 NU PR 105.36 K0067 UE VI 24.59K0069 RR PR 10.54 K0068 NU VI 5.17K0069 UE PR 79.02 K0068 RR VI 0.53K0070 NU PR 193.17 K0068 UE VI 3.88K0070 RR PR 19.32 K0069 NU VI 87.80K0070 UE PR 144.87 K0069 RR VI 8.78K0071 NU PR 115.21 K0069 UE VI 65.85K0071 RR PR 11.53 K0070 NU VI 160.98K0071 UE PR 86.40 K0070 RR VI 16.10K0072 NU PR 69.35 K0070 UE VI 120.73K0072 RR PR 6.93 K0071 NU VI 96.01K0072 UE PR 52.02 K0071 RR VI 9.60K0073 NU PR 35.30 K0071 UE VI 72.00K0073 RR PR 3.53 K0072 NU VI 57.79K0073 UE PR 26.47 K0072 RR VI 5.78K0074 NU PR 33.17 K0072 UE VI 43.35K0074 UE PR 24.90 K0073 NU VI 30.59K0075 NU PR 35.76 K0073 RR VI 3.06K0075 RR PR 4.48 K0073 UE VI 22.94K0075 UE PR 26.82 K0074 NU VI 26.89K0076 NU PR 26.96 K0074 RR VI 2.96K0076 RR PR 2.70 K0074 UE VI 20.17K0076 UE PR 20.21 K0075 NU VI 36.77K0077 NU PR 62.05 K0075 RR VI 4.15K0077 RR PR 6.20 K0075 UE VI 27.58K0077 UE PR 46.54 K0076 NU VI 22.46K0078 NU PR 10.12 K0076 RR VI 2.26K0078 RR PR 1.02 K0076 UE VI 16.85K0078 UE PR 7.59 K0077 NU VI 51.72K0079 NU PR 17.41 K0077 RR VI 5.17K0079 RR PR 2.17 K0077 UE VI 38.78K0079 UE PR 13.06 K0078 NU VI 8.44K0080 NU PR 90.59 K0078 RR VI 0.84K0080 RR PR 11.33 K0078 UE VI 6.31K0080 UE PR 67.94 K0079 NU VI 44.46K0081 NU PR 42.92 K0079 RR VI 4.64K0081 RR PR 4.30 K0079 UE VI 22.21K0081 UE PR 32.19 K0080 NU VI 127.50K0082 NU PR 85.01 K0080 RR VI 13.23K0082 RR PR 10.62 K0080 UE VI 99.24K0082 UE PR 63.76 K0081 NU VI 35.75K0083 NU PR 147.09 K0081 RR VI 3.57K0083 RR PR 14.71 K0081 UE VI 26.81K0083 UE PR 110.32 K0082 NU VI 98.73K0084 NU PR 97.00 K0082 RR VI 9.92K0084 RR PR 9.69 K0082 UE VI 74.05K0084 UE PR 72.76 K0083 NU VI 122.58K0085 NU PR 196.16 K0083 RR VI 12.26K0085 RR PR 19.62 K0083 UE VI 91.94K0085 UE PR 146.86 K0084 NU VI 80.83K0086 NU PR 85.01 K0084 RR VI 8.09K0086 RR PR 10.62 K0084 UE VI 60.63K0086 UE PR 63.76 K0085 NU VI 163.47K0087 NU PR 118.32 K0085 RR VI 16.36

K0087 RR PR 11.83 K0085 UE VI 122.60K0087 UE PR 88.74 K0086 NU VI 98.73K0088 NU PR 354.97 K0086 RR VI 9.92K0088 RR PR 44.37 K0086 UE VI 74.05K0088 UE PR 266.23 K0087 NU VI 98.59K0089 NU PR 79.62 K0087 RR VI 9.86K0089 RR PR 7.96 K0087 UE VI 73.95K0089 UE PR 59.71 K0088 NU VI 226.98K0090 NU PR 80.35 K0088 RR VI 22.69K0090 RR PR 8.04 K0088 UE VI 173.77K0090 UE PR 60.27 K0089 NU VI 66.35K0091 NU PR 21.90 K0089 RR VI 6.62K0091 RR PR 2.19 K0089 UE VI 49.76K0091 UE PR 16.43 K0090 NU VI 66.95K0092 NU PR 256.41 K0090 RR VI 6.70K0092 RR PR 25.64 K0090 UE VI 50.22K0092 UE PR 192.31 K0091 NU VI 18.25K0093 NU PR 160.19 K0091 RR VI 1.82K0093 RR PR 16.03 K0091 UE VI 13.69K0093 UE PR 120.14 K0092 NU VI 213.67K0094 NU PR 52.18 K0092 RR VI 21.36K0094 RR PR 5.22 K0092 UE VI 160.25K0094 UE PR 39.14 K0093 NU VI 133.48K0095 NU PR 52.18 K0093 RR VI 13.35K0095 RR PR 5.22 K0093 UE VI 100.11K0095 UE PR 39.14 K0094 NU VI 43.49K0096 NU PR 289.28 K0094 RR VI 4.36K0096 RR PR 28.92 K0094 UE VI 32.62K0096 UE PR 216.95 K0095 NU VI 43.49K0097 NU PR 63.97 K0095 RR VI 4.36K0097 RR PR 6.40 K0095 UE VI 32.62K0097 UE PR 47.99 K0096 NU VI 241.06K0098 NU PR 27.84 K0096 RR VI 24.10K0098 RR PR 2.79 K0096 UE VI 180.80K0098 UE PR 20.89 K0097 NU VI 55.44K0099 NU PR 85.31 K0097 RR VI 5.55K0099 RR PR 8.53 K0097 UE VI 41.58K0099 UE PR 63.98 K0098 NU VI 23.77K0100 NU PR 91.99 K0098 RR VI 2.38K0100 RR PR 11.51 K0098 UE VI 17.84K0100 UE PR 68.99 K0099 NU VI 71.10K0101 RR PR 47.29 K0099 RR VI 7.12K0102 NU PR 45.72 K0099 UE VI 53.33K0102 RR PR 4.56 K0100 NU VI 75.51K0102 UE PR 34.29 K0100 RR VI 7.50K0103 NU PR 53.88 K0100 UE VI 58.81K0103 RR PR 6.75 K0101 RR VI 38.37K0103 UE PR 40.41 K0102 NU VI 38.10K0104 NU PR 125.26 K0102 RR VI 3.81K0104 RR PR 12.52 K0102 UE VI 28.58K0104 UE PR 93.95 K0103 NU VI 46.24K0105 NU PR 104.85 K0103 RR VI 4.73K0105 RR PR 10.49 K0103 UE VI 35.47K0105 UE PR 78.65 K0104 NU VI 104.39K0106 NU PR 113.02 K0104 RR VI 10.43K0106 RR PR 11.31 K0104 UE VI 78.30K0106 UE PR 84.77 K0105 NU VI 87.39K0107 NU PR 100.34 K0105 RR VI 8.72K0107 RR PR 12.55 K0105 UE VI 65.53K0107 UE PR 75.26 K0106 NU VI 94.18K0112 PR 242.89 K0106 RR VI 9.43K0113 PR 148.16 K0106 UE VI 70.64K0114 PR 755.84 K0107 NU VI 77.66K0115 PR 866.70 K0107 RR VI 7.78K0116 PR 1808.99 K0107 UE VI 58.24K0118 NU PR 30.37 K0112 VI 202.40K0118 RR PR 3.04 K0113 VI 123.46K0118 UE PR 22.78 K0114 VI 629.86K0126 PR 129.76 K0115 VI 722.25K0127 PR 19.20 K0116 VI 1507.49K0128 PR 14.02 K0118 NU VI 25.32K0129 PR 136.98 K0118 RR VI 2.53K0130 PR 63.06 K0118 UE VI 18.99K0132 PR 1.43 K0126 VI 108.13K0133 PR 1.80 K0127 VI 16.01K0134 PR 3.64 K0128 VI 11.68K0135 PR 1.72 K0129 VI 114.15K0136 PR 10.18 K0130 VI 52.55K0137 PR 2.48 K0132 VI 1.24K0138 PR 3.51 K0133 VI 1.53K0139 PR 3.76 K0134 VI 3.11K0148 KB PR 3.87 K0135 VI 1.47K0148 KC PR 11.76 K0136 VI 8.70K0148 KD PR 42.88 K0137 VI 2.12K0148 KE PR 12.24 K0138 VI 3.01



K0149 KB PR 6.35 K0139 VI 3.21K0149 KC PR 13.36 K0148 KB VI 3.53K0149 KD PR 20.76 K0148 KC VI 10.73K0150 KB PR 11.73 K0148 KD VI 39.16K0150 KC PR 16.91 K0148 KE VI 11.19K0150 KD PR 20.76 K0149 KB VI 5.80K0150 KF PR 33.66 K0149 KC VI 12.21K0151 KB PR 7.78 K0149 KD VI 18.95K0151 KC PR 11.80 K0150 KB VI 10.71K0151 KD PR 44.17 K0150 KC VI 15.44K0153 KB PR 0.88 K0150 KD VI 18.95K0153 KC PR 4.10 K0150 KF VI 30.75K0153 KD PR 6.13 K0151 KB VI 7.11K0154 PR 13.83 K0151 KC VI 10.77K0155 NU PR 265.47 K0151 KD VI 40.35K0155 RR PR 26.55 K0153 KB VI 0.88K0155 UE PR 199.10 K0153 KC VI 4.10K0156 RR PR 800.45 K0153 KD VI 6.13K0157 RR PR 38.51 K0154 VI 12.63K0158 RR PR 858.95 K0155 NU VI 221.23K0159 RR PR 889.39 K0155 RR VI 22.12K0160 RR PR 2293.54 K0155 UE VI 165.93K0161 RR PR 1600.91 K0156 RR VI 661.86K0163 PR 442.63 K0157 RR VI 28.27K0165 PR 4.75 K0158 RR VI 736.75L0100 PR 459.85 K0159 RR VI 735.40L0110 PR 93.32 K0160 RR VI 699.81L0120 PR 32.38 K0161 RR VI 1323.73L0130 PR 416.13 K0163 VI 358.10L0140 PR 80.96 K0165 VI 4.07L0150 PR 91.76 L0100 VI 440.04L0160 PR 103.63 L0110 VI 93.62L0170 PR 413.97 L0120 VI 17.29L0172 PR 86.36 L0130 VI 141.74L0174 PR 140.33 L0140 VI 41.72L0180 PR 270.30 L0150 VI 80.59L0190 PR 373.39 L0160 VI 109.19L0200 PR 373.39 L0170 VI 420.26L0210 PR 21.59 L0172 VI 95.36L0220 PR 102.55 L0174 VI 179.01L0300 PR 147.38 L0180 VI 264.28L0310 PR 323.84 L0190 VI 353.98L0315 PR 377.81 L0200 VI 340.86L0317 PR 388.60 L0210 VI 36.66L0320 PR 156.53 L0220 VI 100.58L0330 PR 744.83 L0300 VI 132.65L0340 PR 376.84 L0310 VI 286.40L0350 PR 742.34 L0315 VI 219.44L0360 PR 860.90 L0317 VI 270.66L0370 PR 701.65 L0320 VI 243.46L0380 PR 286.06 L0330 VI 298.70L0390 PR 1159.29 L0340 VI 425.41L0400 PR 1349.32 L0350 VI 663.10L0410 PR 1511.24 L0360 VI 983.42L0420 PR 2104.94 L0370 VI 315.54L0430 PR 1133.43 L0380 VI 540.67L0440 PR 593.70 L0390 VI 1120.33L0500 PR 172.71 L0400 VI 1248.50L0510 PR 274.45 L0410 VI 1240.37L0515 PR 91.76 L0420 VI 1318.78L0520 PR 323.30 L0430 VI 968.61L0530 PR 183.51 L0440 VI 732.85L0540 PR 215.89 L0500 VI 92.15L0550 PR 988.03 L0510 VI 212.53L0560 PR 968.27 L0515 VI 143.86L0565 PR 809.59 L0520 VI 297.33L0600 PR 63.68 L0530 VI 269.96L0610 PR 150.59 L0540 VI 356.50L0620 PR 194.95 L0550 VI 957.54L0700 PR 916.14 L0560 VI 961.10L0710 PR 974.10 L0565 VI 730.74L0810 PR 1536.60 L0600 VI 63.05L0820 PR 997.42 L0610 VI 168.35L0830 PR 1739.54 L0620 VI 367.86L0860 PR 803.12 L0700 VI 1317.42L0900 PR 89.16 L0710 VI 1367.57L0910 PR 185.56 L0810 VI 1706.94L0920 PR 89.16 L0820 VI 1407.59L0930 PR 242.88 L0830 VI 2043.41L0940 PR 134.94 L0860 VI 793.85L0950 PR 317.36 L0900 VI 104.34L0960 PR 59.38 L0910 VI 232.80L0970 PR 46.31 L0920 VI 110.60L0972 PR 46.31 L0930 VI 263.87L0974 PR 75.46 L0940 VI 103.04

L0976 PR 75.46 L0950 VI 252.46L0978 PR 46.31 L0960 VI 45.01L0980 PR 9.88 L0970 VI 77.09L0982 PR 9.88 L0972 VI 74.31L1000 PR 1651.57 L0974 VI 116.67L1010 PR 28.93 L0976 VI 104.19L1020 PR 37.79 L0978 VI 125.43L1025 PR 183.51 L0980 VI 11.38L1030 PR 40.59 L0982 VI 10.61L1040 PR 29.03 L1000 VI 1322.98L1050 PR 29.03 L1010 VI 43.73L1060 PR 46.31 L1020 VI 56.33L1070 PR 38.86 L1025 VI 108.35L1080 PR 11.55 L1030 VI 41.45L1085 PR 104.71 L1040 VI 50.84L1090 PR 40.59 L1050 VI 54.25L1100 PR 52.14 L1060 VI 62.32L1110 PR 104.38 L1070 VI 58.64L1120 PR 16.30 L1080 VI 36.06L1200 PR 1043.72 L1085 VI 100.31L1210 PR 1130.73 L1090 VI 65.55L1220 PR 1188.59 L1100 VI 106.39L1230 PR 1594.58 L1110 VI 166.43L1240 PR 47.21 L1120 VI 25.88L1250 PR 36.23 L1200 VI 1021.01L1260 PR 36.23 L1210 VI 227.34L1270 PR 41.72 L1220 VI 192.48L1280 PR 58.18 L1230 VI 493.91L1290 PR 42.81 L1240 VI 51.07L1300 PR 1592.20 L1250 VI 47.08L1310 PR 1275.65 L1260 VI 49.30L1500 PR 1079.46 L1270 VI 50.49L1510 PR 1727.13 L1280 VI 60.39L1520 PR 2698.64 L1290 VI 51.22L1600 PR 187.07 L1300 VI 1451.36L1610 PR 27.46 L1310 VI 1445.54L1620 PR 90.02 L1500 VI 1237.77L1630 PR 96.62 L1510 VI 1044.08L1640 PR 647.67 L1520 VI 1937.01L1650 PR 107.58 L1600 VI 83.97L1660 PR 104.30 L1610 VI 31.27L1680 PR 809.59 L1620 VI 96.63L1685 PR 917.54 L1630 VI 110.42L1686 PR 863.57 L1640 VI 351.34L1700 PR 1025.48 L1650 VI 150.87L1710 PR 1187.40 L1660 VI 111.52L1720 PR 242.88 L1680 VI 793.97L1730 PR 852.77 L1685 VI 775.12L1750 PR 52.69 L1686 VI 792.56L1755 PR 1187.40 L1700 VI 995.12L1800 PR 68.06 L1710 VI 1164.91L1810 PR 76.74 L1720 VI 858.68L1815 PR 75.56 L1730 VI 757.26L1820 PR 98.55 L1750 VI 170.94L1825 PR 20.86 L1755 VI 1061.92L1830 PR 72.43 L1800 VI 43.34L1832 PR 917.54 L1810 VI 69.99L1834 PR 1025.48 L1815 VI 63.13L1840 PR 863.57 L1820 VI 95.89L1844 PR 441.54 L1825 VI 35.83L1845 PR 626.09 L1830 VI 67.57L1846 PR 663.87 L1832 VI 528.24L1850 PR 269.86 L1834 VI 572.70L1855 PR 966.12 L1840 VI 674.32L1858 PR 1187.40 L1844 VI 565.80L1860 PR 921.96 L1845 VI 669.44L1870 PR 946.90 L1846 VI 889.18L1880 PR 539.73 L1850 VI 205.98L1900 PR 199.70 L1855 VI 954.77L1902 PR 48.58 L1858 VI 854.73L1904 PR 334.63 L1860 VI 851.68L1906 PR 80.96 L1870 VI 840.45L1910 PR 334.63 L1880 VI 544.07L1920 PR 431.78 L1900 VI 175.80L1930 PR 127.60 L1902 VI 68.08L1940 PR 863.57 L1904 VI 316.89L1950 PR 695.82 L1906 VI 79.15L1960 PR 863.57 L1910 VI 216.80L1970 PR 731.40 L1920 VI 243.70L1980 PR 231.98 L1930 VI 154.15L1990 PR 701.65 L1940 VI 409.07L2000 PR 707.65 L1950 VI 647.16L2010 PR 724.10 L1960 VI 481.60L2020 PR 1052.48 L1970 VI 614.99L2030 PR 811.75 L1980 VI 268.45



L4055 PR 296.86 L4000 VI 830.87L4060 PR 172.71 L4010 VI 515.70L4070 PR 172.71 L4020 VI 715.82L4080 PR 80.96 L4030 VI 438.67L4090 PR 80.96 L4040 VI 314.52L4100 PR 97.15 L4045 VI 213.76L4110 PR 97.15 L4050 VI 358.70L4130 PR 296.86 L4055 VI 174.20L4310 PR 647.67 L4060 VI 207.09L4320 PR 53.97 L4070 VI 183.39L4350 PR 45.01 L4080 VI 67.36L4360 PR 208.33 L4090 VI 70.04L4370 PR 120.90 L4100 VI 84.45L4380 PR 83.12 L4110 VI 72.84L5000 PR 566.72 L4130 VI 323.31L5010 PR 566.72 L4310 VI 316.77L5020 PR 782.82 L4320 VI 95.58L5050 PR 2158.91 L4350 VI 58.25L5060 PR 579.89 L4360 VI 187.18L5100 PR 2158.91 L4370 VI 123.02L5105 PR 3778.10 L4380 VI 86.54L5150 PR 3778.10 L5000 VI 350.77L5160 PR 3886.05 L5010 VI 1072.92L5200 PR 3346.32 L5020 VI 1375.82L5210 PR 3130.43 L5050 VI 1698.29L5220 PR 3022.48 L5060 VI 2556.67L5230 PR 2698.64 L5100 VI 1759.50L5250 PR 7016.47 L5105 VI 2939.26L5270 PR 10,309.99 L5150 VI 2707.86L5280 PR 7232.36 L5160 VI 2651.72L5300 PR 2914.53 L5200 VI 2294.43L5310 PR 4641.67 L5210 VI 2246.18L5320 PR 4574.74 L5220 VI 2050.20L5330 PR 8419.76 L5230 VI 2641.02L5340 PR 10,309.99 L5250 VI 3847.54L5400 PR 492.88 L5270 VI 3570.56L5410 PR 150.69 L5280 VI 3534.85L5420 PR 753.89 L5300 VI 1959.56L5430 PR 2698.64 L5310 VI 3035.74L5450 PR 208.77 L5320 VI 2926.67L5460 PR 260.90 L5330 VI 4087.60L5500 PR 1295.35 L5340 VI 4483.63L5505 PR 2266.86 L5400 VI 835.55L5510 PR 1727.13 L5410 VI 290.07L5520 PR 1727.13 L5420 VI 1055.26L5530 PR 684.04 L5430 VI 465.80L5535 PR 1813.49 L5450 VI 314.64L5540 PR 1781.10 L5460 VI 378.55L5560 PR 2590.70 L5500 VI 891.64L5570 PR 742.12 L5505 VI 1207.51L5580 PR 985.76 L5510 VI 1010.73L5585 PR 2590.70 L5520 VI 1219.73L5590 PR 2590.70 L5530 VI 1199.12L5595 PR 4317.83 L5535 VI 1316.84L5600 PR 4857.56 L5540 VI 1256.55L5610 PR 2158.91 L5560 VI 1576.67L5611 PR 1133.43 L5570 VI 1588.09L5613 PR 1430.29 L5580 VI 1800.03L5616 PR 809.59 L5585 VI 1776.27L5618 PR 181.15 L5590 VI 1852.05L5620 PR 274.45 L5595 VI 3085.92L5622 PR 701.65 L5600 VI 3413.87L5624 PR 384.18 L5610 VI 1437.35L5626 PR 863.57 L5611 VI 1118.55L5628 PR 734.03 L5613 VI 1701.38L5629 PR 323.84 L5616 VI 942.89L5630 PR 208.77 L5618 VI 205.77L5631 PR 485.76 L5620 VI 228.35L5632 PR 58.08 L5622 VI 335.58L5634 PR 81.23 L5624 VI 291.60L5636 PR 58.08 L5626 VI 331.00L5637 PR 701.65 L5628 VI 346.10L5638 PR 87.01 L5629 VI 294.18L5639 PR 2050.97 L5630 VI 314.74L5640 PR 174.01 L5631 VI 406.72L5642 PR 202.94 L5632 VI 167.91L5643 PR 782.61 L5634 VI 247.57L5644 PR 231.98 L5636 VI 235.86L5645 PR 458.77 L5637 VI 255.88L5646 PR 376.84 L5638 VI 406.49L5647 PR 523.54 L5639 VI 991.60L5648 PR 463.85 L5640 VI 591.89L5649 PR 1079.46 L5642 VI 513.30L5650 PR 755.62 L5643 VI 1080.55L5651 PR 755.62 L5644 VI 410.05




L8626 PR 2585.12 L8613 VI 231.77L8627 PR 187.20 L8614 VI 231.77L8628 PR 187.20 L8615 VI 196.12L8629 PR 187.20 L8620 VI 187.20L8630 PR 196.12 L8622 VI 213.93L8641 PR 187.20 L8623 VI 213.93L8642 PR 187.20 L8624 VI 213.93L8655 PR 196.12 L8625 VI 187.20L8656 PR 196.12 L8626 VI 2585.12L8657 PR 187.20 L8627 VI 187.20L8658 PR 111.43 L8628 VI 187.20L8690 PR 156.00 L8629 VI 187.20V2020 PR 32.93 L8630 VI 196.12V2100 PR 32.93 L8641 VI 187.41V2101 PR 32.93 L8642 VI 187.20V2102 PR 32.93 L8655 VI 196.12V2103 PR 32.93 L8656 VI 196.12V2104 PR 32.93 L8657 VI 187.20V2105 PR 32.93 L8658 VI 111.43V2106 PR 32.93 L8690 VI 156.00V2107 PR 32.93 V2020 VI 43.52V2108 PR 32.93 V2100 VI 36.25V2109 PR 32.93 V2101 VI 38.21V2110 PR 32.93 V2102 VI 44.23V2111 PR 44.74 V2103 VI 31.49V2112 PR 44.74 V2104 VI 34.86V2113 PR 44.74 V2105 VI 37.96V2114 PR 44.74 V2106 VI 41.93V2116 PR 54.89 V2107 VI 40.06V2117 PR 60.39 V2108 VI 39.88V2118 PR 60.39 V2109 VI 44.36V2200 PR 40.89 V2110 VI 45.29V2201 PR 40.89 V2111 VI 47.21V2202 PR 40.89 V2112 VI 51.53V2203 PR 40.89 V2113 VI 56.64V2204 PR 40.89 V2114 VI 62.92V2205 PR 40.89 V2115 VI 53.03V2206 PR 40.89 V2116 VI 50.20V2207 PR 40.89 V2117 VI 59.15V2208 PR 40.89 V2118 VI 58.17V2209 PR 40.89 V2200 VI 47.45V2210 PR 40.89 V2201 VI 51.39V2211 PR 51.87 V2202 VI 58.30V2212 PR 51.87 V2203 VI 47.88V2213 PR 40.89 V2204 VI 49.15V2214 PR 51.87 V2205 VI 53.58V2215 PR 51.87 V2206 VI 54.14V2216 PR 65.60 V2207 VI 49.83V2217 PR 71.37 V2208 VI 51.46V2219 PR 6.10 V2209 VI 52.31V2220 PR 54.89 V2210 VI 55.88V2300 PR 55.99 V2211 VI 58.05V2301 PR 55.99 V2212 VI 58.96V2303 PR 55.99 V2213 VI 61.17V2304 PR 55.99 V2214 VI 74.52V2305 PR 55.99 V2215 VI 69.27V2306 PR 55.99 V2216 VI 63.91V2307 PR 55.99 V2217 VI 68.76V2308 PR 55.99 V2218 VI 90.11V2309 PR 55.99 V2219 VI 38.78V2310 PR 55.99 V2220 VI 33.43V2311 PR 66.97 V2300 VI 58.54

V2312 PR 66.97 V2301 VI 56.53V2313 PR 66.97 V2302 VI 57.34V2314 PR 66.97 V2303 VI 55.88V2315 PR 112.31 V2304 VI 60.26V2316 PR 105.13 V2305 VI 62.17V2317 PR 105.18 V2306 VI 63.80V2318 PR 147.89 V2307 VI 61.50V2319 PR 29.68 V2308 VI 61.57V2320 PR 65.87 V2309 VI 63.34V2410 PR 96.33 V2310 VI 64.40V2430 PR 138.76 V2311 VI 62.09V2500 PR 219.56 V2312 VI 62.48V2501 PR 247.02 V2313 VI 70.37V2502 PR 246.15 V2314 VI 80.22V2503 PR 137.07 V2315 VI 99.96V2510 PR 219.56 V2316 VI 101.58V2511 PR 246.15 V2317 VI 97.36V2512 PR 246.15 V2318 VI 135.78V2513 PR 219.56 V2319 VI 39.50V2520 PR 219.56 V2320 VI 48.49V2521 PR 247.02 V2410 VI 76.77V2522 PR 247.02 V2430 VI 100.02V2523 PR 220.53 V2500 VI 75.24V2530 PR 139.47 V2501 VI 114.60V2623 PR 512.75 V2502 VI 141.18V2624 PR 54.60 V2503 VI 130.03V2625 PR 210.39 V2510 VI 87.70V2626 PR 125.97 V2511 VI 147.58V2627 PR 713.84 V2512 VI 174.37V2628 PR 545.88 V2513 VI 146.40V2630 PR 595.03 V2520 VI 96.54V2631 PR 323.86 V2521 VI 168.07V2632 PR 395.21 V2522 VI 163.56V2700 PR 32.99 V2523 VI 130.31V2710 PR 87.82 V2530 VI 154.84V2715 PR 55.44 V2623 VI 804.61V2718 PR 28.54 V2624 VI 42.26V2730 PR 4.30 V2625 VI 256.95V2740 PR 8.78 V2626 VI 138.51V2741 PR 8.78 V2627 VI 1097.57V2742 PR 8.78 V2628 VI 214.55V2743 PR 8.78 V2700 VI 35.06V2744 PR 8.78 V2710 VI 59.35V2750 PR 27.25 V2715 VI 10.75V2755 PR 9.05 V2718 VI 24.53V2760 PR 5.72 V2730 VI 14.64V2770 PR 21.96 V2740 VI 9.44V2780 PR 21.96 V2741 VI 9.11XX002 PR 23.04 V2742 VI 9.28XX004 PR 8.13 V2743 VI 9.63XX006 PR 3.92 V2744 VI 11.54XX007 PR 11.21 V2750 VI 14.22XX008 PR 0.54 V2755 VI 11.53XX011 PR 1.52 V2760 VI 11.78

V2770 VI 17.38V2780 VI 8.69XX002 VI 23.04XX004 VI 8.13XX006 VI 3.92XX007 VI 11.21XX008 VI 0.54XX011 VI 1.52



TELEPHONE DIRECTORY

Region C DMERC

Region C DMERC Professional Relations ............................................................................... (803) 735-1034Region C DMERC Ombudsmen ........................................................................ (Please refer to page 94-87.)Region C DMERC General Information ..................................................................................1-800-847-4432

Electronic Data Interchange ..................................................................................................... (803) 788-9751Prior Authorization .................................................................................................................... (803) 735-9353Anti-Fraud and Abuse Unit ....................................................................................................... (803) 788-5414

National

HCPCS Help-Line..................................................................................................................... (803) 736-6809National Supplier Clearinghouse.............................................................................................1-800-851-3682

The Region C DMERC Medicare Advisory is published by Palmetto Government Benefits Administrator's Professional Relations Depart-ment for suppliers and providers of DMEPOS. Questions regarding information in Palmetto GBA publications can be addressed to:

Palmetto Government Benefits AdministratorsProfessional Relations Department

P.O. Box 100141Columbia, SC 29202-3141

or call (803) 735-1034, Ext. 5740 or Ext. 5741


GLOSSARY

AARP American Association of Retired PersonsALJ Administrative Law JudgeARU Audio Response UnitAWP Average Wholesale PriceCMN Certificate of Medical NecessityDME Durable Medical EquipmentDMEPOS Durable Medical Equipment, Prosthetics, Orthotics, and SuppliesDMERC Durable Medical Equipment Regional CarrierEDI Electronic Data InterchangeEFT Electronic Funds TransferEMC Electronic Media ClaimEOB Explanation of BenefitsEOMB Explanation of Medicare BenefitsERN Electronic Remittance NoticeFDA Food and Drug AdministrationHCFA Health Care Financing AdministrationHCPCS HCFA Common Procedure Coding SystemHICN Health Insurance Claim NumberICD-9-CM International Classification of Diseases-9th Revision-Clinical ModificationIPPB Intermittent Positive Pressure BreathingMSP Medicare Secondary PayerNDC National Drug CodeNSC National Supplier ClearinghouseNSF National Standard FormatNTIS National Technical Information ServiceOBRA 93 Omnibus Budget Reconciliation Act of 1993OCNA Other Carrier Name & AddressOIG Office of Inspector GeneralP & O Prosthetics & OrthoticsPalmetto GBA Palmetto Government Benefits AdministratorsPDR Physician's Desk ReferencePEN Parenteral and Enteral NutritionPOS Place of ServicePOV Power Operated VehicleRMRP Regional Medical Review PoliciesRRB Railroad Retirement BoardSAC Supplier Advisory CommitteeSADMERC Statistical Analysis Durable Medical Equipment Regional CarrierTENS Transcutaneous Electrical Nerve StimulatorUPIN Unique Physician Identification Number


CUMULATIVE INDEX

1993 Reasonable Charge Pricing K Codes ....................................................................................................94-281994 Durable Medical Equipment Fee Schedule Corrections ..........................................................................94-961994 HCFA Common Procedure Coding System HCPCS Update ...................................................................94-631994 Pricing Matrix

1994 Pricing Matrix ........................................................................................................................... 94-33-521994 Pricing Matrix for Virgin Islands and Puerto Rico....................................................................... 94-97-107

Advantis Network ........................................................................................................................................94-76Anti-Fraud and Abuse Unit ...........................................................................................................................94-90Certificate of Medical Necessity

Certificate of Medical Necessity: Deferred Implementation .........................................................................94-4Certificate of Medical Necessity Submission ....................................................................................... 94-11-12

Certified Software Vendors, Billing Services & Clearinghouses .................................................................. 94-77-84Claim Payment ....................................................................................................................................... 94-14-15Claims Jurisdiction .................................................................................................................................. 94-15-18Coding: How to Obtain Reference Material .....................................................................................................94-6Complementary Insurers ................................................................................................................... 94-20, 94-63Crossover Problem Identified .......................................................................................................................94-57DMEPOS Supplier Specialty Workshops Notice.............................................................................................94-85DMERC Certified Software Vendors ......................................................................................................... 94-22-26Electronic Data Interchange (EDI) Help-Line: Commonly Asked Questions ......................................................94-75Electronic Data Interchange (EDI) Update .....................................................................................................94-76Electronic Media Claims (EMC) Agreements ............................................................................................ 94-21-22Glossary .........................................................................................................................................94-54, 94-109Grandfathering Policy ...............................................................................................................................94-7-10HCFA Common Procedure Coding System (HCPCS)

Coding Help-Line: Commonly Asked Questions .................................................................................. 94-64-65Additions/Changes ........................................................................................................................... 94-65-66Codes Requiring A CMN ................................................................................................................... 94-67-71

ICD-9-CM Information ..................................................................................................................................94-26Level II HCPCS Codes for Elevating Leg Rests ...............................................................................................94-5Lymphedema Pumps/Pneumatic Compressors ..............................................................................................94-19Medical Policy

Medical Policy: Where DMERC Medical Policy Does Not Exist .................................................................94-13Medical Policy Important Update.............................................................................................................94-20

Medicare Part B Carrier's Manual: How To Obtain ........................................................................................94-90National K Code Pricing ...............................................................................................................................94-27National Supplier Clearinghouse

NSC Change of Address Notification .......................................................................................................94-29NSC Change of Address Notification Form ..............................................................................................94-29

New HCPCS Level III Codes for Enteral Products .........................................................................................94-6-7Notice of Transition Delays ...........................................................................................................................94-58OBRA 93 Changes .....................................................................................................................................94-1-3Ombudsmen Addresses and Their Territories ................................................................................................94-87Oral Anticancer Drugs ............................................................................................................................. 94-60-63PEN Supply and Administration Kits ..............................................................................................................94-90Physician Order .............................................................................................................................................94-4Place of Service (POS) ................................................................................................................................94-85Prescription Before Delivery .........................................................................................................................94-71Prior Authorization Process ..........................................................................................................................94-88Professional Relations Staff ..........................................................................................................................94-86Questions & Answers ...................................................................................................................94-30-32, 94-89Recategorization of New Wheelchair Codes ....................................................................................................94-5Revised State-By-State Transition Schedule ..................................................................................................94-59SADMERC's HCPCS Functions ..................................................................................................................94-4-5Service Access ...........................................................................................................................................94-89Supplier Advisory Committee .......................................................................................................................94-85Telephone Directory ........................................................................................................................94-53, 94-108Transition Tips ....................................................................................................................................... 94-72-74Unique Physician Identification Number (UPIN) Directory: How To Obtain ......................................................94-90Using the OCNA Matrix ........................................................................................................................... 94-91-95Workload Transition Reminder .....................................................................................................................94-19


- NOTES -


To facilitate the most expedient and functional testing of both the vendor software used to file electronicDMEPOS claims in the National Standard Format and the users who will file of those claims, PalmettoGovernment Benefits Administrators (Region C DMERC) has implemented the following procedures for testingand problem resolution during testing:

GETTING STARTED: ACQUIRING A SUBMITTER ID

Any entity (vendor, supplier, billing service or clearinghouse) wishing to become certified by Region C must havea supplier number from the National Supplier Clearinghouse and a Submitter ID from Palmetto EDI. To obtaina supplier number, contact the NSC at 1-800-851-3682. Please contact the Palmetto GBA EMC Help Desk at(803) 788-9751 and request a Submitter ID/Testing Request Form or send a written request for this form toPalmetto GBA EDI, P.O. Box 100145, Columbia, SC 29202-3145.

These forms are self-explanatory and request information such as your modem type and speed, the filetransmission protocol you will use, your software vendor (if any), monthly claims volume and demographicinformation about your company. This information will help to determine which of our 12 standard test packagesyou need.

Note: Suppliers, billing services and clearinghouses using certified vendor software are not required to use TestPackages for testing. Refer to Testing Requirements below to determine whether or not you need to requestTest Packages to complete your testing.

TESTING AND CERTIFICATION REQUIREMENTS

Software VendorsA software vendor seeking to have its software certified by Palmetto GBA as having the ability to transmitDMEPOS claims and Certificates of Medical Necessity in the National Standard format must submit tests toRegion C, using the DMERC NSF Standard Test Packages. Once a vendor is NSF certified by one DMERC,that vendor is considered to be certified by all four DMERCs. It is not necessary to perform NSF certificationtesting with more than one DMERC. However, connectivity testing must be performed witheach DMERC to ensure the ability to connect to the host at each DMERC site.

There are 12 Standard Test Packages and their content correlates with each of the 12 possible Certificates ofMedical Necessity. Your customers may need to send with their claims. Those packages are:

1. Hospital Bed/Support Surfaces2. Manual/Motorized Wheelchairs3. Respiratory Equipment4. Prosthetics/Orthotics/Lymphedema Pump, Osteogenesis Stimulator/Therapeutic Shoes5. Surgical Dressings/Urological Supplies6. TENS7. Seat Lift Mechanisms/Power Operated Vehicles (POV)8. Immunosuppressive Drugs9. Infusion Pump/Home Glucose Monitor10. Parenteral or Enteral Nutrition11. Oxygen12. Items not requiring CMNs

Vendors must submit tests using all Test Packages for which they seek certification. After successfully testingwith these packages, the vendor will be notified of certification by Palmetto GBA and placed on the CertifiedVendor List. This list is distributed to potential electronic submitters and contains demographic and certificationinformation about each vendor certified by each DMERC. The list will note those packages for which the vendorsoftware has been certified.

Certified vendors will be mailed a written certification notice upon certification, indicating each package for whichthey have been certified.


Suppliers, Billing Services or Clearinghouses Using Certified Vendor SoftwareSubmitters using certified vendor software must achieve a 95% or better claims acceptance rate on a minimumof 20 claims comprised of any of the following combinations:

TOP 11 DMERC EDI FRONT END ERRORS

1) INVALID PAYER OR PROVIDER NAME

This error does not mean that the wrong name has been entered; it means that the name has been enteredin an incorrect format. The NSF rules for the entry of individual names are:

First and last names must be at least two positions in length.Middle initial must contain A-Z or may be blank.First position must be (A-Z) and cannot be a blank.The name may contain A-Z, hyphens or a blank.Titles (Dr., Mrs., Mr.) are not allowed.No other special characters are allowed.

Company names must be entered according to the following criteria:

First position must be A-Z.May contain A-Z, period (.), comma (,), hyphen (-), ampersand (&) or blank.Must be at least two positions in length.No other special characters are allowed.

If you receive an Invalid Payer or Provider Name error, correct the error by ensuring that the name enteredmeets all the criteria above.Invalid Payer or Provider Address.

2) INVALID Payer, PROVIDER, FACILITY, (ANY) ADDRESS

Invalid Address errors are resultant of an address not entered in accordance with the following criteria:

Address 1 and 2:May not contain a blank in the first position of any address line.Must contain at least one embedded blank.May contain A-Z, 0-9, forward slash (/), period (.), comma (,), number sign (#), ampersand (&), parentheses(), percent sign (%) or a blank.No other special characters are allowed.

City: May contain A-Z, period (.), comma (,), ampersand (&) or a blank. No other special characters areallowed.

State, Zip: Must be a valid state abbreviation or zipcode

3) INVALID (ANY) DATE

This error could mean one of two things; either you have entered a date in the incorrect format or dependingon the type of date error, you have entered a date that is actually invalid. The format for entering dates isCCYYMMDD (century 18, 19 or 20; month 01 -12; year 01 - 31.

If your date is entered using this criteria, your error is the result of a truly invalid date. For example, the datea piece of equipment was prescribed could not be prior to the date the patient was seen by the orderingphysician.

4) TEST SUBMITTER ID IN PRODUCTION

This error occurs when a provider who has not been certified (either in error or because he has not completed

March 1994 DMERC Medicare Advisory Page 94-115certification testing) attempts to submit claims in production. All claims will be rejected as a result of this error.If Palmetto GBA has contacted you and confirmed that you are certified, please contact the Palmetto GBA EDIHelp Desk and log a call indicating that you have incurred this error. If you have not completed your certificationtesting, complete the testing process before attempting to submit production claims.

5) DOCUMENT INDICATOR INVALID

The documentation indicator specifies where the required documentation supporting a claim can be found. Thiserror indicates that an invalid code has been entered. Valid codes are:

3 - on file at provider site4 - on file at payer’s site5 - cert record in this claim (with or w/o narration).6 - narrative record included in this claim9 - no documentation

The most often used codes will be “5”, if a CMN is submitted with the claim; and “9” when the claim requiresno CMN.

6) RECEIVER ID INVALID

When electronic claims are submitted to a DMERC, you must indicate through your software program, whichDMERC is to receive the claims. The codes for the DMERCs are Region A = 10555, Region B = 00635, RegionC = 00885 and Region D = 05655.

7) FORM XX/QX/GUO-XX

This error, FORM XX/QX/GUO-XX, with the X’s replaced by numbers, indicates that a specific form (CMN) hasis in error because a specific question on that form was incorrectly left unanswered or answered with aninappropriate code.

For example, FORM 04/Q4/GU0-29, means that on CMN #4 (Prosthetics/Orthotics/Lymphedema Pump,Osteogenesis Stimulator/Therapeutic Shoes) question #4 is either not answered (and must be) or is answeredwith an invalid value. The “-29” indicates the format field number in error. This error can occur on any CMNand any question.

Valid responses to questions, other than those requiring numeric values or narrative, both of which areexplained on the CMN, are Y = Yes, N = No and D = Does Not Apply.

(8-11) INSURANCE INFORMATION ERRORS

WHAT IS A “SECONDARY PAYER” CLAIM?When a DMEPOS claim is submitted, Medicare is most often the “primary payer” or the insurance companythat will make first payment on the claim. If a beneficiary has a Medigap policy or Medicaid, these insurancesare considered “secondary payers” and any charges remaining after Medicare has paid the allowable amountfor the claim may be paid by one of these “secondary payers.

WHAT IS AN “MSP” CLAIM?“MSP” stands for “Medicare Secondary Payer.” In some instances, Medicare will not be the primary payer ofa DMEPOS claim. In this instance, another insurance is the primary payer and Medicare is considered thesecondary payer.

FACTS ABOUT SECONDARY PAYER CLAIMS, CROSSOVER and MSPClaims with Medicaid as the Secondary Payer will be crossed over for participating and nonparticipatingproviders.

There is a difference between supplemental policies and Medigap policies:

Supplemental policies are those offered by an employer to employees and former employers to formeremployees or by labor unions to members or former members.

116 March 1994 DMERC Medicare AdvisoryMedigap policies are policies offered by private insurance carriers to individuals who are entitled to Medicarebenefits. Medigap policies pay for those Medicare-approved charges not reimbursable due to deductibles,coinsurance amounts and other limitations.

Supplemental policies are not automatically crossed over and should not be listed as secondary payers whenfiling electronically. However, if a supplemental insurer has voluntarily elected to enter into an agreement withPalmetto GBA for automatic crossover of Medicare claim information to that insurer, that claim will be crossedover and your Medicare remittance will indicate that this did occur.

Claims with Medigap Secondary Payers will only be crossed over when the beneficiary elects to assign theirMedigap benefits to a participating provider. The Medigap crossover process eliminates the need forbeneficiaries or participating providers to file separate claims to Medigap insurers. Therefore, only participatingproviders need file secondary payer claims for Medigap.

The four errors listed below are often incurred together and are almost always found in the InsuranceInformation records for MSP or Secondary Payer claims. Medicare Secondary Payer and Secondary Payerclaims can be confusing, but you can avoid or correct errors by entering your claim information in the fieldsdiscussed according to the guidelines outlined below.

8) INVALID SEQUENCE NUMBER (All Insurance Information Records)

When you file a claim for which there are two or more payers (primary, secondary and tertiary), you mustcomplete an insurance information record for each payer. You will indicate, through your software, which recordyou are completing by entering a sequence number for each record.

01 = Primary Payer Record02 = Secondary Payer Record03 = Tertiary Payer Record

ENTERING VALUES ON YOUR PRIMARY Payer RECORD

9) SOURCE OF PAY INVALID (Primary Payer Record 01)

You will base your Source of Payment Indicator on which record you are completing; in this case we arecompleting the Primary Payer Record.

If Medicare is primary, enter “C” in the Source of Pay field on the Primary Pay Record (01).

If insurance other than Medicare is primary, the appropriate codes to enter in the Source of Pay field for thePrimary Payer record are:

A - Self PayB - Worker’s CompensationE - Other Federal ProgramF - Commercial Insurance CompanyG - Blue Cross/Blue ShieldH - ChampusI - HMOJ - FEPK - Central CertificationL - Self-administeredM - Family or Friends

Enter one of these valid codes in the Source of Pay field when the primary payer is not Medicare.

INSURANCE TYPE CODE INVALID (Primary Payer Record - 01)If you entered “C” in the Source of Pay field on this record, enter “MP” in the Insurance Type Code field. Youwill not be required to enter Payer ID (Org) Number or Payer Claim Office Number when Medicare is primaryand you have entered a “C” in the Source of Pay field and “MP” in the Insurance Type Code field.

If you entered a value other than “C” (Medicare) in the Source of Pay field in this record, you are submitting aMedicare Secondary Payer (MSP) claim and you are indicating in this field which insurance is primary. Match

March 1994 DMERC Medicare Advisory Page 94-117that value with the appropriate code defining the type of insurance you have stipulated as the primary payer.Valid codes are:

IP - Individual PolicyGP - Group PolicyLT - LitigationLD - Long Term PolicyPP - Personal Payment (Cash - No Insurance)AP - Auto Insurance PolicyOF - Other (Not Medicaid in this instance)

If you have questions about the correct Insurance Type Codes to Match with the Source of Pay indicated,contact your DMERC Team.

ENTERING VALUES ON YOUR SECONDARY Payer RECORD

Source of Pay (Secondary Payer Record - 02)If your secondary payer is Medicare, enter “C” in the Source of Pay field on your Secondary Payer Record (02).

If your secondary payer is Medicaid, enter “D” in the Source of Pay field on your Secondary Payer Record (02)

Insurance Type Code (Secondary Payer Record - 02)If you entered a value of “D” (Medicaid) in the Source of Pay field on this record, enter “OT” (Medicaid) in theInsurance Type Code field. You are not required to enter the Payer ID or Payer Claim Office Number whenMedicaid is indicated as payer.

If you entered a value of “Z” (Other-Medigap) in the Source of Pay field on this record, enter “MG” (Medigap)in the Insurance Type Code field. You are required to enter Payer ID and Payer Claim Office Number whenMedigap is indicated as payer.

10) Payer ORG ID MISSING (First 5 characters of the OCNA Number)

11) Payer CLAIM OFF INVALID (Last 4 characters of the OCNA Number)These fields only require entry when you are completing a Secondary Payer (02) record and the secondarypayer is Medigap.

Payer Org ID: Enter the first five character of the Medigap insurer’s OCNA (Other Carrier Name and Address)number.

Payer Claim Office Number: Enter the last four characters of the Medigap insurer’s OCNA number.

A list of OCNA numbers is furnished in Appendix E of your Palmetto GBA Supplier’s Manual. To request aSupplier’s Manual if you do not have one, contact your DMERC team.

One batch of 20 or more “live” claims- the submitter’s own, actual claims that he plans to submit in productiononce he is certified.

One batch containing all the claims (minimum total of 20) from the two (or more, if desired) test packages thatcontain the two types of claims the submitter will most often submit. For example a supplier who primarily sellsoxygen and hospital beds would choose to submit packages 1 and 11. MSP claims may be omitted, providedthey are replaced with the same number of claims from another package or the submitter’s “live” claim.

A batch consisting of any combination of claims from “live” claims and test packages, provided that a minimumof 20 claims are submitted.

Suppliers, Billing Services and Clearinghouses Using Uncertified SoftwareSuppliers, billing services and clearinghouses using uncertified software should submit one batch containingall the claims (minimum total of 20) from the two (or more, if desired) test packages that contain the two typesof claims the submitter will most often submit. For example, a supplier who primarily sells prosthetics andorthotics and power operated vehicles would choose to submit packages 4 and 7. MSP claims may be omitted,provided they are replaced with the same number of claims from another package.

118 March 1994 DMERC Medicare AdvisoryBilling services and clearinghouses will be placed on the Certified Vendor List after certification testing has beencompleted. The list will note those packages for which the billing service or clearinghouse has been certified.

Notification of CertificationYou will not be contacted after submitting a test(s) unless you have satisfied certification criteria (see guidelinesbelow). When you have achieved certification, a Palmetto GBA EDI staff member will contact you by telephonewithin 24 hours of receiving your successful test.

A written notification of certification will be provided to certified billing services and clearinghouses uponcompletion of certification testing.

Connectivity Testing for Entities Certified by Other DMERCsAny entity wishing to submit claims to Palmetto GBA must test for connectivity with Palmetto. This testinginvolves testing only the ability to transmit claims to and retrieve error reports from Palmetto. Call the PalmettoGBA EMC Help Desk and indicate that you have already completed NSF certification with another DMERC,have a Submitter ID and would like to test for connectivity with Palmetto GBA. A Palmetto GBA EDI staff memberwill return your call and assist you in setting up communications with Palmetto GBA.

SUBMITTING YOUR TESTS AND REVIEWING YOUR ERRORS

Submitting TestsRegion C test cycles run at noon and 8:00 p.m. daily, Monday through Saturday. Submit your test claimsaccording to the guidelines outlined above that pertain to your company.

Retrieving Your Error ReportsAfter submitting your test claims, wait until after the next test cycle is run and then retrieve your Control and ErrorReports electronically. (If you are a diskette or tape submitter and cannot retrieve your error reportselectronically, please request in a note enclosed with your tape or diskette submission that you would like yourerror reports mailed or faxed to you. Please state your fax number if you wish your reports faxed.) Error reportsfaxed or mailed only to tape or diskette submitters.

Almost all certified software vendors include a “script” or program to retrieve your reports. The Palmetto GBALowcost Software Version 1.01 and Procomm Command File, or version 01.02 of the software includes thisfeature.

Please ensure that your vendor has installed a report retrieval program before contacting Region C withproblems retrieving reports. If you are certain that your report retrieval program is installed and in working order,but you still have difficulty retrieving your reports, please contact the Palmetto GBA EMC Help Desk.

If your software vendor does not have a program built into your system for report retrieval, contact your vendorand request that this feature be added. In the mean time, contact the Palmetto GBA EMC Help Desk and requestTechnical Specifications which will help you retrieve your reports.

About Your Error ReportsYour error reports will tell you how many claims you sent, how many and which claims were accepted andrejected and provide a brief explanation of all errors in every record of each rejected claim. Review your errorscarefully, correct them and submit another test. Make sure that you submit at least 20 claims. Repeat thisprocess until you have achieved the 95% acceptance rate required for NSF certification.

REPORTING AND GETTING HELP WITH EDI PROBLEMS DURING TESTING AND IN PRODUCTION

Using the EMC Help Desk

If you have problems in testing or production or receive errors you do not understand, please contact the EMCHelp Desk at (803) 788-9751. State that you are currently testing and the specific nature of your problem. Forexample:

“I am testing and need assistance analyzing my error report.”“I am testing and connect with you; the error I get when trying to connect is“I am testing and cannot retrieve my error reports.”

March 1994 DMERC Medicare Advisory Page 94-119“I am submitting (or have submitted) production claims. I am having problems with...”

The key words to use are “testing” and “production;” this will help us better prioritize and direct your calls. Yourcall will be answered by a Palmetto GBA EDI staff member, who will return your call in the order it was received.

Note: Please help us respond to your calls as quickly as possible! Do not contact individual EDI staff membersat their extensions. Call the Help Desk with all EDI questions and concerns. All DMERC EDI staff respond toproblem calls logged through the Help Desk in the order they were received.

WHAT KINDS OF CALLS CAN BE RESOLVED BY PALMETTO GBA EDI

The Palmetto GBA Region EDI (electronic data interchange) Department is responsible for receiving yourelectronic claims in the National Standard Format for DMEPOS claims, performing front-end edits to ensurethat the claims have been entered in the correct format and providing error reports to you electronically or, inthe case of tape or diskette submitters, by mail.

Below is a list of the kinds of calls EDI can resolve:

Connecting to the Region C host (supported protocols only).Acquiring a submitter ID, test packages, lowcost software, a certified vendor list, NSF specifications, an NSFMatrix.Getting started with and performing testing.Retrieving error reports.Assistance interpreting error reports.Clarifying format questions.Basic assistance with Palmetto GBA lowcost software usage.Assistance with EDI problems regarding production claims.

Below are examples of calls that should not be directed to EDI:

Acquisition of an NSC Supplier number.(Contact the National Supplier Clearinghouse at (800) 851-3682)

Questions about valid codes, Medical Policy, payment on claims, development of claims, supplier workshops,claims adjudication, crossover contract, SADMERC issues. (Contact your DMERC Operations Team at (800)847-4432)

Questions about claims data entry other than the Palmetto GBA lowcost software. (Contact your softwarevendor)

Questions specific to other DMERCs and/or claims sent to other DMERCs. (Contact the appropriate DMERC)

TOP 11 DMERC EDI FRONT END ERRORS

1) INVALID PAYER OR PROVIDER NAME

This error does not mean that the wrong name has been entered; it means that the name has been enteredin an incorrect format. The NSF rules for the entry of individual names are:

First and last names must be at least two positions in length.Middle initial must contain A-Z or may be blank.First position must be (A-Z) and cannot be a blank.The name may contain A-Z, hyphens or a blank.Titles (Dr., Mrs., Mr.) are not allowed.No other special characters are allowed.

Company names must be entered according to the following criteria:

First position must be A-Z.May contain A-Z, period (.), comma (,), hyphen (-), ampersand (&) or blank.Must be at least two positions in length.No other special characters are allowed.


If you receive an Invalid Payor or Provider Name error, correct the error by ensuring that the name enteredmeets all the criteria above.Invalid Payer or Provider Address.

2) INVALID Payer, PROVIDER, FACILITY, (ANY) ADDRESS

Invalid Address errors are resultant of an address not entered in accordance with the following criteria:

Address 1 and 2:May not contain a blank in the first position of any address line.Must contain at least one embedded blank.May contain A-Z, 0-9, forward slash (/), period (.), comma (,), number sign (#), ampersand (&), parentheses(), percent sign (%) or a blank.No other special characters are allowed.

City: May contain A-Z, period (.), comma (,), ampersand (&) or a blank. No other special characters areallowed.

State, Zip: Must be a valid state abbreviation or zipcode

3) INVALID (ANY) DATE

This error could mean one of two things; either you have entered a date in the incorrect format or dependingon the type of date error, you have entered a date that is actually invalid. The format for entering dates isCCYYMMDD (century 18, 19 or 20; month 01 -12; year 01 - 31.

If your date is entered using this criteria, your error is the result of a truly invalid date. For example, the datea piece of equipment was prescribed could not be prior to the date the patient was seen by the orderingphysician.

4) TEST SUBMITTER ID IN PRODUCTION

This error occurs when a provider who has not been certified (either in error or because he has not completedcertification testing) attempts to submit claims in production. All claims will be rejected as a result of this error.If Palmetto GBA has contacted you and confirmed that you are certified, please contact the Palmetto GBA EDIHelp Desk and log a call indicating that you have incurred this error. If you have not completed your certificationtesting, complete the testing process before attempting to submit production claims.

5) DOCUMENT INDICATOR INVALID

The documentation indicator specifies where the required documentation supporting a claim can be found. Thiserror indicates that an invalid code has been entered. Valid codes are:

3 - on file at provider site4 - on file at payor’s site5 - cert record in this claim (with or w/o narration).6 - narrative record included in this claim9 - no documentation

The most often used codes will be “5”, if a CMN is submitted with the claim; and “9” when the claim requiresno CMN.

6) RECEIVER ID INVALID

When electronic claims are submitted to a DMERC, you must indicate through your software program, whichDMERC is to receive the claims. The codes for the DMERCs are Region A = 10555, Region B = 00635, RegionC = 00885 and Region D = 05655.


7) FORM XX/QX/GUO-XX

This error, FORM XX/QX/GUO-XX, with the X’s replaced by numbers, indicates that a specific form (CMN) hasis in error because a specific question on that form was incorrectly left unanswered or answered with aninappropriate code.

For example, FORM 04/Q4/GU0-29, means that on CMN #4 (Prosthetics/Orthotics/Lymphedema Pump,Osteogenesis Stimulator/Therapeutic Shoes) question #4 is either not answered (and must be) or is answeredwith an invalid value. The “-29” indicates the format field number in error. This error can occur on any CMNand any question.

Valid responses to questions, other than those requiring numeric values or narrative, both of which areexplained on the CMN, are Y = Yes, N = No and D = Does Not Apply.

(8-11) INSURANCE INFORMATION ERRORS

WHAT IS A “SECONDARY Payer” CLAIM?When a DMEPOS claim is submitted, Medicare is most often the “primary payer” or the insurance companythat will make first payment on the claim. If a beneficiary has a Medigap policy or Medicaid, these insurancesare considered “secondary payers” and any charges remaining after Medicare has paid the allowable amountfor the claim may be paid by one of these “secondary payers.

WHAT IS AN “MSP” CLAIM?“MSP” stands for “Medicare Secondary Payer.” In some instances, Medicare will not be the primary payer ofa DMEPOS claim. In this instance, another insurance is the primary payer and Medicare is considered thesecondary payer.

FACTS ABOUT SECONDARY Payer CLAIMS, CROSSOVER and MSPClaims with Medicaid as the Secondary Payer will be crossed over for participating and nonparticipatingproviders.

There is a difference between supplemental policies and Medigap policies:

Supplemental policies are those offered by an employer to employees and former employers to formeremployees or by labor unions to members or former members.

Medigap policies are policies offered by private insurance carriers to individuals who are entitled to Medicarebenefits. Medigap policies pay for those Medicare-approved charges not reimbursable due to deductibles,coinsurance amounts and other limitations.

Supplemental policies are not automatically crossed over and should not be listed as secondary payers whenfiling electronically. However, if a supplemental insurer has voluntarily elected to enter into an agreement withPalmetto GBA for automatic crossover of Medicare claim information to that insurer, that claim will be crossedover and your Medicare remittance will indicate that this did occur.

Claims with Medigap Secondary Payers will only be crossed over when the beneficiary elects to assign theirMedigap benefits to a participating provider. The Medigap crossover process eliminates the need forbeneficiaries or participating providers to file separate claims to Medigap insurers. Therefore, only participatingproviders need file secondary payer claims for Medigap.

The four errors listed below are often incurred together and are almost always found in the InsuranceInformation records for MSP or Secondary Payer claims. Medicare Secondary Payer and Secondary Payerclaims can be confusing, but you can avoid or correct errors by entering your claim information in the fieldsdiscussed according to the guidelines outlined below.

8) INVALID SEQUENCE NUMBER (All Insurance Information Records)

When you file a claim for which there are two or more payers (primary, secondary and tertiary), you must


complete an insurance information record for each payer. You will indicate, through your software, which recordyou are completing by entering a sequence number for each record.

01 = Primary Payer Record02 = Secondary Payer Record03 = Tertiary Payer Record

ENTERING VALUES ON YOUR PRIMARY Payer RECORD

9) SOURCE OF PAY INVALID (Primary Payer Record 01)

You will base your Source of Payment Indicator on which record you are completing; in this case we arecompleting the Primary Payer Record.

If Medicare is primary, enter “C” in the Source of Pay field on the Primary Pay Record (01).

If insurance other than Medicare is primary, the appropriate codes to enter in the Source of Pay field for thePrimary Payer record are:

A - Self PayB - Worker’s CompensationE - Other Federal ProgramF - Commercial Insurance CompanyG - Blue Cross/Blue ShieldH - ChampusI - HMOJ - FEPK - Central CertificationL - Self-administeredM - Family or Friends

Enter one of these valid codes in the Source of Pay field when the primary payor is not Medicare.

INSURANCE TYPE CODE INVALID (Primary Payer Record - 01)If you entered “C” in the Source of Pay field on this record, enter “MP” in the Insurance Type Code field. Youwill not be required to enter Payer ID (Org) Number or Payer Claim Office Number when Medicare is primaryand you have entered a “C” in the Source of Pay field and “MP” in the Insurance Type Code field.

If you entered a value other than “C” (Medicare) in the Source of Pay field in this record, you are submitting aMedicare Secondary Payer (MSP) claim and you are indicating in this field which insurance is primary. Matchthat value with the appropriate code defining the type of insurance you have stipulated as the primary payer.Valid codes are:

IP - Individual PolicyGP - Group PolicyLT - LitigationLD - Long Term PolicyPP - Personal Payment (Cash - No Insurance)AP - Auto Insurance PolicyOF - Other (Not Medicaid in this instance)

If you have questions about the correct Insurance Type Codes to Match with the Source of Pay indicated,contact your DMERC Team.

ENTERING VALUES ON YOUR SECONDARY Payer RECORD

Source of Pay (Secondary Payer Record - 02)If your secondary payer is Medicare, enter “C” in the Source of Pay field on your Secondary Payer Record (02).

March 1994 DMERC Medicare Advisory Page 94-123If your secondary payer is Medicaid, enter “D” in the Source of Pay field on your Secondary Payer Record (02)

Insurance Type Code (Secondary Payer Record - 02)If you entered a value of “D” (Medicaid) in the Source of Pay field on this record, enter “OT” (Medicaid) in theInsurance Type Code field. You are not required to enter the Payer ID or Payer Claim Office Number whenMedicaid is indicated as payer.

If you entered a value of “Z” (Other-Medigap) in the Source of Pay field on this record, enter “MG” (Medigap)in the Insurance Type Code field. You are required to enter Payer ID and Payer Claim Office Number whenMedigap is indicated as payer.

10) Payer ORG ID MISSING (First 5 characters of the OCNA Number)

11) Payer CLAIM OFF INVALID (Last 4 characters of the OCNA Number)These fields only require entry when you are completing a Secondary Payer (02) record and the secondarypayer is Medigap.

Payer Org ID: Enter the first five character of the Medigap insurer’s OCNA (Other Carrier Name and Address)number.

Payer Claim Office Number: Enter the last four characters of the Medigap insurer’s OCNA number.

A list of OCNA numbers is furnished in Appendix E of your Palmetto GBA Supplier’s Manual. To request aSupplier’s Manual if you do not have one, contact your DMERC team.

Under current Federal Regulations, it is possible for Medicare to make a secondary payment, even if the primaryinsurer pays more than the Medicare allowed amount on a claim. The amount of Medicare secondary payment(MSP) is the lower of:

The amount that Medicare would pay if there was no other primary insurer; orThe higher allowed amount (either the primary insurer’s allowed amount or Medicare’s allowed amount) minus

the primary insurer’s payment.

Mandatory Claims Filing Under MSP

If you are aware that the patient has other primary insurance, you may (but are not required to) send a claimto the primary insurer. If you receive the claim determination directly from the primary insurance, you areresponsible for submitting a claim to Medicare for secondary benefits. If you did not accept assignment on theprimary insurance but the beneficiary furnishes a copy of the primary insurer’s explanation of benefits andrequests that you submit a claim to Medicare, you must submit a Medicare claim on their behalf.

The following are ways in which the secondary payment is calculated under Medicare Part B:

Routine MSP CalculationSupplier Billed ....................................................................$ 500.00Medicare Allowable ...............................................................375.00Primary Insurance Allowable .................................................500.00Primary Insurance Paid .........................................................400.00

The secondary payment would be the higher of:

Medicare Allowable ...............................................................375.00 or

MEDICARE ASSECONDARY PAYER(MSP)


Primary Allowed Amount .......................................................500.00

Less the primary paid amount .....................................................400.00Medicare’s secondary payment ..................................................100.00

Unmet Primary Insurance DeductibleSupplier Billed ....................................................................$ 500.00Medicare Allowable ...............................................................375.00Primary Insurance Allowable .................................................500.00Primary Insurance Paid .............................................................0.00


Medicare Allowable ...............................................................375.00 orPrimary Allowed Amount .......................................................500.00

Less the primary paid amount .........................................................0.00Medicare’s secondary payment ................................................ 300.00** (80% of $375.00)

Unmet Medicare DeductibleSupplier Billed ....................................................................$ 500.00Medicare Allowable ...............................................................375.00Unmet Medicare Deductible ..................................................100.00Primary Insurance Allowable .................................................500.00Primary Insurance Paid .........................................................400.00


Medicare Allowable ...............................................................375.00 orPrimary Allowed Amount .......................................................500.00

Less the primary paid amount .....................................................400.00Medicare’s secondary payment ..................................................100.00

Patient’s deductible status would be changed from “unmet” to “met”.

Medicare Secondary Payor claims should be submitted with a copy of the original claim and a copy of the EOBfrom the primary insurer to your Team Address which can be found in section 21.

Medicare Secondary Payer (MSP) payments are based on the higher allowable charge between the primaryinsurer and Medicare. All secondary payments are calculated as follows:

1. The Medicare payment is determined in the usual manner, (i.e., as if there were no other insurancecoverage).

2. The higher of the Medicare allowable charge or the primary insurer’s allowable charge is determined.3. The amount paid by the primary insurer is subtracted from the amount determined in number two.4. Medicare pays the lower of number one or number three.

Medicare coordinates benefits up to the higher allowable charge, At no time, however, will Medicare pay moreas a secondary payer than it would have paid as a primary payer.

When to Bill Medicare as a Secondary Payer

When a patient has other insurance that is primary, Medicare may be used as, and should be used as, asecondary payer of benefits after the other insurance.


APPEALS PROCESS DMEPOS suppliers have the right to appeal a claims processing decision if thesupplier accepted assignment and there is dissatisfaction with the amount ofpayment, the denial of coverage for services or supplies, or the original claimwas not acted upon within a reasonable time.

There are five steps in the appeals process as provided by Medicareregulations:

ReviewDMERC Fair Hearing by Carrier Hearing OfficerAdministrative Law Judge (ALJ) HearingAppeals CouncilJudicial Review

The review process provides a complete reexamination of all informationsubmitted with the original claim. A review may be requested by telephone orin writing.

Telephone reviews will usually be completed within the time-frame of the callunless additional information is required. The telephone associate will instructyou as to where to send additional information if necessary. Informationtransmitted during the course of a telephone review may be subject to averification audit.

For written requests, Palmetto Government Benefits Administrators (Pal-metto GBA) asks that you allow us up to 45 days to complete the request, ifnecessary.

The time limit for filing a request for review is six months from the date ofissuance of the remittance notice.

After the initial review, if you are still dissatisfied with the decision, you mayrequest a DMERC Fair Hearing. A DMERC Fair Hearing request must bemade within six months from the date of the review decision notification, andthe amount in controversy must be $100.00 or more.

If, after the claim has been through the DMERC Fair Hearing process, you arestill dissatisfied, you have the right to a hearing before an Administrative LawJudge (ALJ). If the remaining amount in controversy is at least $500.00, youmay request an ALJ Hearing by writing the DMERC, within 60 days of receiptof the DMERC Fair Hearing decision.

If you do not agree with the ALJ's decision, you may ask the Appeals Councilto review the decision within 60 days. To file an appeal, the claimant or hisrepresentative must request in writing that the Appeals Council review theALJ's decision. The request may be filed at any Social Security office or mailedto the address listed in the ALJ's hearing decision.

If you are still dissatisfied after the ALJ Hearing and the amount in controversyis at least $1,000.00, you are entitled to a judicial review before a FederalDistrict court judge. The ALJ Hearing decision would provide you withinstructions on how to request the judicial review.

As part of their responsibilities, the Region C DMERC Dedicated Work TeamAssociates will be handling your appeals requests. Information on how tocontact your Dedicated Work Team has been published in the November 1993issue of the DMERC Medicare Advisory and is in the Region C DMEPOSSupplier Manual.