The terms that show up on decision letters, ADRs, and MAC portals — explained plainly, with the policy source. For what Medicare requires per equipment category, see the requirement guides.
A Medicare reviewer's written request for the records behind a claim; miss the deadline on the letter and the claim is denied without review.
The two outcomes of a DMEPOS prior authorization request: a provisional affirmation clears the claim to be paid, a non-affirmation does not.
The CMS forms (the CMS-484 oxygen CMN and others) that certain DME claims once required; retired for dates of service on or after January 1, 2023.
The Medicare program that awards DMEPOS contracts by bid in designated areas; no contracts are in effect during the current gap, and Round 2028 is coming.
One of the two private contractors, Noridian or CGS, that process Medicare DMEPOS claims and prior authorizations across a four-jurisdiction map.
The in-person or qualifying telehealth visit where the treating practitioner evaluates the patient for the item, within the 6 months before the order.
The code set every DMEPOS claim is billed under; Level II codes are a letter plus four digits, such as E0601 for CPAP or E1390 for an oxygen concentrator.
Which of the four DME MAC regions (A, B, C, or D) a claim belongs to, set by the beneficiary's permanent address on file with Social Security.
A MAC's published coverage policy for an item, listing the clinical criteria a claim must meet; for DME the LCDs are joint across all four DME MACs.
The practitioner's estimate, in months, of how long the patient will need an item; 99 meant lifetime on the retired CMN forms. Optional on the SWO.
The 11-character ID on the Medicare card that replaced the SSN-based HICN; the SWO may use the MBI in place of the beneficiary's name.
A CMS coverage decision that applies nationwide and binds every MAC; where no NCD exists, the MACs may set coverage through LCDs.
The 10-digit HIPAA identifier every provider carries; the treating practitioner's name or NPI is a required element on the SWO.
The billing and coding article attached to an LCD, plus the DME MAC Standard Documentation Requirements article (A55426) reviewers apply alongside it.
Medical review of a claim before it is paid: the MAC suspends the claim, issues an ADR, and decides based on the records you return.
Medicare's pre-delivery review for listed DMEPOS items; the DME MAC issues a provisional affirmation or non-affirmation before you deliver and bill.
Suppliers with a 90 percent affirmation rate on 10 or more PA requests can skip PA for a year, per PTAN and jurisdiction; the first cycle began June 2026.
The signed record that a specific item reached a specific beneficiary on a specific date; required for every DME claim and kept for 7 years.
Your Medicare enrollment number, assigned when enrollment is approved and tied to your NPI; used to authenticate with the MAC, not submitted on claims.
The single order format Medicare has required for all DMEPOS since January 1, 2020, defined in 42 CFR 410.38(d) with six required elements.
A MAC medical review program: up to three rounds of 20 to 40 claims each, with one-on-one education between rounds, for suppliers with high error rates.
The 14-character number the DME MAC assigns to a prior authorization decision; it must be on the claim, and on any resubmission, to link them.
CMS adds codes, the DME MACs revise LCDs, cycle deadlines arrive. We send a short note the week it happens, with what to do about it. No drip campaign. Unsubscribe in one click.