Several AOPA members had reported having an issue with select lower limb prosthetic claims being rejected with the remark code CO-261 (The procedure or service is inconsistent with the patient’s history). Since the claims were rejected and not denied the claim could not be appealed; it could only be fixed and resubmitted. However, there was no information or directions provided as to what was “inconsistent”, and how it could be fixed. This inability to fix/appeal the claims was also causing some members to miss their timely filing window.
AOPA, over the last several months, has been working diligently with key staff members at the DME MACs, the DME MAC Medical Directors and high-ranking CMS officials to find a reasonable solution and provide a pathway for suppliers to appeal these rejections; especially for those who may have missed their timely filing windows. The DME MAC Medical Directors recently informed AOPA that the issue has been resolved, and that they will be contacting the affected suppliers and provide them with directions on how to resubmit and/or appeal their claims.