On January 11, 2018, Performant Recovery, the National DMEPOS RAC, added ventilators to their approved issues list. According to their website, Performant Recovery will perform complex reviews on ventilator claims subject to DWO requirements on or after January 1, 2016 to determine if coverage criteria and/or medical necessity requirements were met.

Codes included in the audit: E0465, E0466

Applicable policy references:

  • Social Security Act, Section 1833. [42 U.S.C. 1395l] (e)
  • Medicare Claims Processing Manual: CMS Publication 100-04; Chapter 12, § 40.3 Claims Review for Global Surgeries
  • 42 C.F.R. sections 405.980 (b) & (c) and section 405.986
  • 42 CFR 424.57(a)(12)
  • Title XVIII, Social Security, §1862(a)(1)(A)
  • CMS, IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Sections 110
  • CMS, IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 4, Section 4.26
  • CMS, IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 5, Section 5.2.4 – 5.2.8, 5.7, 5.8, and 5.9
  • CMS, IOM Publication 100-04, Medicare Claims Processing Manual Chapter 20
  • CMS, IOM Publication 100-03, Medicare National Coverage Determination Manual, Chapter 1, Part 4, §280.1
  • CMS Policy Article A55426 for Standard Documentation Requirements for All Claims


Want some help? Come to the experts! 

The van Halem Group offers proactive and reactive services to assist you. If you receive an audit request from the RAC our clinical team will review the claim file and respond to the audit on your behalf. If denied, we will work with you to obtain addendums and appeal the overpayment.

Want to feel confident that the ventilators you are providing meet coverage criteria? Sign up for our ventilator prescreen program.

Before you put out the equipment, let our clinical staff review your documentation to ensure the ventilator meets coverage criteria. Our clinicians will review your documentation and provide you with an “approved” or “denied” status, along with recommendations for your referral source. Get your documentation right before you bill the claim to Medicare, and rest easy knowing you are protected should those claims be audited in the future.  In fact, we feel so confident in our clinical prescreen process, if you receive a denial on a claim that received vHG “approval”, we will appeal on your behalf – for free*! That is how confident we are in our ventilator prescreen program.

Contact us for more information!

*Claim must be submitted with same documentation provided at prescreen level. Any changes or alterations void free appeal.