DMEPOS Updated Refill Request and Affirmative Response Requirements

Medicare Part B/DMEPOS billing and documentation rules are VERY different from most of your pharmacy claims. If you don’t have a strong grasp of these differences, or a process for handling the documentation, then you are sure to experience significant problems during an audit. PAAS Audit Assistance members can download PAAS’ Basic DMEPOS Documentation Guidance resource for a helpful checklist when processing these claims.

This Newsline article focuses on the refill record request and affirmative response requirement that was updated January 1, 2024. Suppliers can find all the revisions in CMS Final Rule 1780-F. DMEPOS items and supplies that are provided on a recurring basis must be based on prospective, not retrospective, use. Medicare requires documentation to ensure the item(s) remain reasonable and necessary, existing supplies are expected to end, and to confirm if there are any changes to the order. If your pharmacy currently has a process for documenting a proof of refill request, PAAS National® would recommend you review and update your form if necessary to meet Medicare’s requirements.

The refill record request, at a minimum, must include:

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  1. Requestor’s name (beneficiary or authorized representative)
  2. A description of each item being requested
  3. Documentation of an affirmative response indicating a need for the refill
    • Includes confirmation that the beneficiary is still using the item
    • No changes have been made to the order
    • A refill is needed
  4. Date of the request

PAAS Tips:

  • For an item that the beneficiary obtains in-person at your pharmacy, the signed delivery slip or copy of an itemized sales receipt is sufficient documentation for a refill request and affirmative response
  • For an item that is delivered to the beneficiary, there must be documentation recorded from the beneficiary, or their authorized representative, affirming the need for a refill
    • The refill request must occur, and be documented, before shipment or delivery
  • Contact with the beneficiary, or authorized representative, must take place no sooner than 30 calendar days before the expected end of the current supply
  • Medicare states suppliers are permitted to use any mode of communication if the beneficiary affirmation is received, documented and can be produced upon request
    • This affirmation can occur through a phone call, an email, a text message, or in-person
  • The supplier must provide the DMEPOS product no sooner than 10 calendar days before the expected end of the current supply – regardless of whether the refill is picked up in the pharmacy or delivered
  • Medicare believes the new requirements take the burden off both suppliers and beneficiaries by:
    • Extending the time frame for the supplier to contact the beneficiary with an affirmative response (went from 14 to 30 calendar days)
    • No longer requiring beneficiaries to “count” their remaining on-hand supplies
    • Changing the terminology of “pending exhaustion” to “expected end of the current supply”
  • Download PAAS’ Proof of Refill Request and Affirmative Response form on the Member Portal where you can document the required information from the beneficiary or their caregiver

Jennifer Ottman, CPhT