Noridian Finds 85% Error Rate on Oxygen Claims

FARGO, N.D. — On Thursday, Noridian Administrative
Services reported the results of a prepayment review of claims for
oxygen concentrators (E1390) and portable gaseous oxygen systems
(E0431), and those results aren’t exactly good.

Of 102 claims reviewed, the Jurisdiction D DME MAC said, 86 were
denied for an overall error ratio of 85 percent.

Noridian ran the review from November through January based on
the results of Comprehensive Error Rate Testing (CERT)
analysis.

The DME MAC cited as the top four reasons for denial:

1) No office visit notes to determine medical necessity within
30 days of certification or 90 days within recertification were
submitted (39 claims);

2) No response to medical records request (33 claims);

3) No qualifying blood gas study submitted (30 claims); and

4) Invalid Certificate of Medical Necessity (CMN) (13
claims).

(The total claim volume is more than 102 as some of the claims
had multiple errors.)

Noridian noted the patient must be seen and evaluated by the
treating physician within 30 days prior to the date of initial
certification. For patients initially meeting Group I or II
criteria, the patient must be seen and re-evaluated by the treating
physician within 90 days prior to the date of any recertification.
If the physician visit is not obtained within the 90-day window but
the patient continues to use oxygen and the visit is obtained at a
later date, coverage would resume beginning with the date of that
visit.

For the DME MAC’s explanation of the denial reasons, see the
full notice on the Noridian Web site.