Understanding Medicare Part B documentation requirements can be difficult. Local Coverage Determinations and associated Policy Articles for each DMEPOS category, along with the Standard Documentation Requirements for All Claims Submitted to DME MACs, are filled with billing and documentation guidelines which suppliers must fully comprehend and follow to avoid claim chargebacks. The PAAS National®® 2026 DMEPOS Series is […]
Many pharmacies struggle with Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) audits due to the complexity in medical billing and the onerous documentation requirements. To help you alleviate those challenges, PAAS is starting a new DMEPOS series. The series is intended to help you understand these complexities and be sure you have valid, supporting […]
PAAS National®® saw the number of validation requests/claim reviews increase 22% in 2025. While OptumRx® sends out most of the validation requests/claim reviews, we also see them from Caremark, Express Scripts, Humana, MagellanRx, Medimpact, and Prime Therapeutics. Three additional PBMs began to do the reviews in 2025 and those are Meridian, Pharmastar and some Medicaid […]
PAAS National®® analysts have repeatedly seen auditors targeting claims with potentially undocumented substitution issues. Albuterol HFA inhalers are one of the top products [incorrectly] substituted that can lead to claim recoupment. Pharmacies should utilize the chart and PAAS Tips below to better understand pharmacy level substitution of Albuterol HFA inhalers to reduce the risk of […]
Over the past few years, the number of medications available and prescribed for migraine prevention and treatment has notably increased, which leads to additional audit risks. PBMs continue to monitor and audit migraine medications due to their high cost, often incalculable instructions and common billing errors. Our PAAS National®® analyst team wants to help you […]
Santyl® ointment is a high dollar topical medication with specific instructions for application which carries high audit risk and potential recoupment from your pocket. Pharmacies need to follow the guidance below to help reduce their audit risk.
CMS rolled out the Targeted Probe and Educate (TPE) program back in 2017. The goal of the TPE program is to help providers reduce the number of DMEPOS claim denials by using data analysis and providing one-on-one educational sessions to avoid common mistakes. DME Medicare Administrative Contractors (MACs) analyze data to identify providers who have […]
PAAS National®® analysts field many questions on Ozempic® relating to off-label use; however, we also receive questions about what days’ supply to submit on claims – particularly for initiation dosing. Section 2.2 of the manufacturer package insert (available on DailyMed) lists the recommended dosage schedule based on clinical trials and includes the following titration schedule: […]
Per NCPDP’s Telecommunication Version D and Above: Questions, Answers and Editorial Updates, “the Prescription Origin Code (419-DJ) contains the value that represents the method in which the pharmacy originally received the prescription from the prescriber.” Any subsequent changes or modifications to the original prescription do not change the origin code even when clarifications of that […]
PAAS National®® continues to see a large number of EPIPEN® prescriptions flagged for audit, as well as targeted on OptumRx prescription validation requests. The PBMs often target EPIPEN® products due to their higher cost and confusion around proper billing practices and product substitution. Adhering to the guidance below can help avoid billing issues and reduce […]
