06/09/2020

Medicaid DME Denial-Secondary

DM pt. with MCare and MCaid. MCaid is denying secondary payment for DM shoes, inserts (A5500, A5514 with proper KX, L, R modifiers, PCP DLS, etc.). Procedure is inconsistent w/provider type/specialty (taxonomy). Refer to 835 healthcare policy ident. segment (loop 2110 serv. pmt. info. ref. Is this every going to be corrected? Last modified 9/20/09.

The denial from Medicaid will not be corrected- the cause is because podiatrists and DME suppliers are credentialed in different ways by Medicaid. While Medicare and many commercial insurances (even some Medicaid managed care plans) allow for podiatrists to dispense a limited number of medically necessary DME items to patients, FFS Medicaid does not allow it, even if the primary insurance covers the charges. The only way for a podiatrist to get reimbursed for diabetic shoes or other items is to separately enroll as a DME supplier with Medicaid. Enrollment under a second specialty is the only potential way to be reimbursed for any co-insurance or deductibles that are not covered under the podiatry taxonomy by FFS Medicaid when secondary to Medicare or a commercial payer.