Your DME Claim Went to the Wrong DME MAC?
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Here’s a Five-Minute, Permanent Fix
This is a very common issue. Take a deep breath—don’t panic.
In most cases, this can be resolved by your biller and a one-time, five-minute call to your IT company. Nearly all EHR systems are familiar with this problem and can implement a simple fix to prevent it from happening again.Why Did This Happen?
Before reviewing the solution, here’s some quick background on Fee-for-Service Medicare and how DME claims are routed:
- DME MACs are not the same contractors that process medical or surgical claims.
- Medical/surgical claims are paid based on where the service was provided (your office location).
- DME claims are processed by the DME MAC assigned to the patient’s legal home address.
- The place of service (your office address) is still used on the patient’s written proof of delivery.
The Root Cause
This issue typically occurs when a patient’s legal home address is:
- In a different state, and
- In a different DME MAC jurisdiction than your office.
This is especially common among geriatric “snowbird” patients.
The Simple Fix
- Confirm the patient’s legal home address
This is the address where the patient resides for more than six months per year, as declared with the IRS and Social Security.
Example:
Many patients legally reside in Florida, but spend summers with family in New Jersey or other northern states.- Once the patient’s legal address is updated, that information flows into the Medicare Common Working File (CWF).
- Correct the claim by:
- Updating the patient’s address to their legal home address (e.g., Florida), and
- Repricing the claim using the appropriate state DME fee schedule.
- Resubmit the claim to the correct DME MAC.
Anything Else I Need to Do?
Yes—there are a few small items to review to ensure this never happens again. The first three should be discussed with your IT company.
- Multiple Patient Addresses in Your EHR
Can your EHR manage multiple addresses (e.g., seasonal or “snowbird” addresses)?
Most systems can—and your IT vendor can usually implement this quickly.- Claims Submitted via a Clearinghouse
If you use a clearinghouse, your IT company can configure the system to automatically route DME claims based on the patient’s legal address.
- Claims Submitted Electronically Directly to the DME MAC
If you bypass a clearinghouse, your IT team likely already has what’s needed. In some cases, you may need to contact the DME MAC Provider Assistance line to complete a one-time setup document.
- Paper Claims
If submitting paper claims, simply:
- Correct the patient’s address, and
- Mail the claim directly to the appropriate DME MAC.
Key Takeaway
The DME MAC that processes and pays your claim is determined by the patient’s legal home address and where they are expected to use their DME equipment—not by your office location.
Although Medicare systems are supposed to automatically route claims to the correct DME MAC, this frequently does not happen, resulting in claim rejections.
By confirming and correctly maintaining patient legal addresses—especially for seasonal patients—you can easily prevent this issue going forward.
If needed, call your IT company and/or the appropriate DME MAC for assistance.
The Good News
- Claims sent to the wrong Fee-for-Service DME MAC are not appealable
- They can be resubmitted to the correct DME MAC
- You may even benefit financially—some states (e.g., Florida) have higher DME fee schedules than the state where services were provided
