Noridian Prepayment Review Results


Noridian, the Jurisdiction D Durable Medical Equipment Medicare Administrative Contractor (DME MAC), recently released their quarterly results of its review for claims involving the HCPCS codes L1832, L1843, L0648, L0650 and L4361.

Between April 2016 and July 2016 Noridian reviewed 161 claims involving the L1832 and 152 claims were denied; resulting in a 99% error/denial rate. The previous denial/error rate was 100%.  The review of claims involving the L1843 had a denial/error rate of 98%; 111 of 112 claims were denied.

The top four denial reasons were listed as:

  • Documentation submitted didn’t justify the need for a custom fitted brace
  • Documentation did not support the presence of knee instability or that the beneficiary is ambulatory
  • Documentation was not submitted in response to the Additional Documentation Request
  • Invalid/Incomplete/Missing proof of delivery

Noridian released their quarterly results of its prepayment review for L0648 and L0650. Between April 2016 and July 2016 Noridian reviewed 275 claims involving the L0648 and 186 claims were denied; resulting in a 64% error/denial rate. The previous quarter’s denial rate (January-April) was 74%.  The review of claims involving the L0650 had a denial/error rate of 83%; 425 of 512 reviewed claims were denied.  The previous quarter’s denial rate (January-April) was 82%.

Some of the top denial reasons listed included:

  • Invalid/Missing/Incomplete detailed written orders
  • Documentation was not submitted in response to the Additional Documentation Request
  • Invalid/Incomplete/Missing proof of delivery

Noridian also released their quarterly results for claims involving HCPCS code L4361 (walking boot, pneumatic and/or vacuum, with or without joints, with or without interface material, prefabricated, off-the-shelf). Between April 2016 and July 2016 Noridian reviewed 378 claims or the L4361, and 270 were denied. This resulted in a claim denial/error rate of 73%.

The top four denial reasons were listed as:

  • Invalid/Missing/Incomplete detailed written orders
  • Documentation was not submitted in response to the Additional Documentation Request
  • Invalid/Incomplete/Missing proof of delivery
  • Documentation didn’t support basic coverage criteria (patient was ambulatory, patient had a weakness/deformity of the ankle, potential to benefit, etc.)

Based on the high denial/error rates Noridian will continue with the prepayment review for all of those codes.

Questions? Contact Devon Bernard at dbernard@AOPAnet.org or Joe McTernan at jmcternan@AOPAnet.org.