North Carolina Medicaid: Avoid denied DMEPOS claims

When filing Medicaid claims for Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) that have no rate assigned, you must include the manufacturer’s invoice showing the price of the item. This step will support the item’s actual cost and help ensure we properly reimburse you for payment.

We’ll deny claims in these instances:

• The invoice isn’t included with the submission
• The price of the item on the invoice doesn’t match the claim line(s) billed

How to file a DMEPOS claim

You can bill multiple units for the same item on the same claim line of the CMS-1500 form. Use separate claim lines to bill different items. Mark each invoice line so it can be matched to the appropriate claim line.

If the HCPCS code isn’t listed on the invoice, please take the following steps to identify the codes billed on the claim:

• Write the description of the item(s) in line 24.D of the CMS-1500 claim form
• Include a handwritten note on the claim
• Circle the item description on the invoice or mark the item with a star or some other indicator
• Upload the invoice with your claim submission

Claim filing examples

• Correct billing – The claim lines on the invoice show multiple items billed with the same description and unit price

          Manufacturer’s invoice:

Lines 24.D–G on the CMS-1500 claim form:

The diagnosis pointer in box E of the claim form identifies the reason for the service performed. You can enter up to 12 diagnosis codes in line 21.E on the claim form.

To help identify the DMEPOS items being billed, it’s important to tie the manufacturer’s invoice to the item on the claim. Do this by adding the item’s HCPCS to the invoice and the item description or product ID from the invoice to the claim.

Note that the HCPCS code on the claim doesn’t always represent the product name. Some items haven’t been assigned a specific HCPCS. You’ll bill these using an unlisted/miscellaneous code such as E1399, as shown in the diagram below.

• Incorrect billing – The service lines on the CMS-1500 claim form don’t match the invoice 

          Manufacturer’s invoice:

Lines 24.D–G on the CMS-1500 claim form:

PCA-1-24-01599-POE-NN_05292024