Advanced Determination of Medicare Coverage is a program to help beneficiaries and suppliers of medical equipment determine whether the purchase of a customized wheelchair will be covered before the item is purchased. Although an approval is not the same as a guarantee, it can give Medicare recipients a good idea of their claim will be paid.
The main advantage to obtaining an Advanced Determination of Medical Coverage is that, if a request is denied, the beneficiary may decide to purchase a less expensive wheelchair since he knows he is unlikely to be reimbursed for the cost.
In order to receive an Advanced Determination of Medicare Coverage, the beneficiary must submit an application. An approval or denial will then be made based on whether it is deemed that the customized wheelchair is a medical necessity for the beneficiary.
Requests for Advanced Determination of Medicare Coverage may be denied for many reasons. One possible reason for rejection is because the wheelchair that is requested is not eligible for ADMC. Other common reasons rejections are given are incomplete request forms, errors on the request form, a duplicate request, making more than two requests within six months or if the service location is a skilled nursing facility or hospital.
If the initial request for Advanced Determination of Medicare Coverage is denied, the beneficiary may reapply one time during the next six months after the date the request was denied. The only allowable reason for a resubmission is if the beneficiary is providing additional documentation to prove the medical necessity of the wheelchair.
Once the ADMC request is submitted, the Medical Review clinician will make a decision within thirty days. Both the supplier and the beneficiary will receive written notice of the decision, along with the reason for rejection if the request is not approved. Once approved, the Advanced Determination of Medicare Coverage is valid for six months from the determination date.