Q: AFO claims are not being processed by my DME Carrier. What do I do?
My AFO claims (custom and off the shelf) are being rejected by my clearinghouse, which has sent me a list of the rejections claiming the modifiers are wrong. When I print my claims the KX and RT or LT modifier are coming out and in that order. I was advised by my clearinghouse to switch the order of the modifiers, to no avail. When I contacted my DME carrier, they claimed they never received the claims. The same thing is happening to my cane or crutch claims when I use the NU and KX modifiers. How to resolve this problem?
If the DME carrier is not receiving the claims this indicates there may be a problem with the communication between your software and your clearinghouse or the clearinghouse and the DME carrier. This is known as a “front end rejection”. That is the error is so egregious that the carrier cannot process the claim beyond its initial filtering and thus the claim is both rejected and non-appealed. And thus the claim does not even appear in the DME MAC system.
While the payment (KX) modifier should theoretically go first before the site (LT or RT) modifier, that should not result in a front-end rejection. My advice would be to submit some of these claims manually, particularly if you have the exception of doing so. If the claim is processed, then clearly something is getting lost in the translation between you and the carrier and most likely it is not your fault but that of your clearinghouse.
Another alternative is to contact the DME MAC and speak with a level two supervisor, while your clearinghouse is on the line. Those two parties may be able to clear up any inconsistencies resulting in this sort of rejection.
As this is indeed a rare event, it so happens, I received another query like this which was forwarded to the DME MAC ombudsmen for clarification. Stay tuned!
