Which claim form need to use for DME billing?

Billing/Claim Formats



The DME MAC and the A/B MAC (B) are billed on the ASC X12 837 professional claim format or if permissible Form CMS-1500.
The A/B MAC (A) (including the A/B MAC (HHH)) is billed on the ASC X12 837 institutional claim format or if permissible Form CMS-1450.

Note that the ASC X12 formats support reporting of the CMNs in the FRM segment

The National Council for Prescription Drug Programs (NCPDP) Telecommunications Standard Version D0 and Batch Standard 1.2 is the HIPAA standard for electronic retail pharmacy drug claims and related coordination of benefits (COB).

Beneficiary Submitted Claims must contain an enrolled Medicare Supplier Number.


This standard will be used by all DME MACs that process retail pharmacy drug transactions. All other claims submitted to the DME MCA by pharmacies, other than retail pharmacy drug claims, must be sent in the ASC X12 837 professional claim format.


Requirements for Implementing the NCPDP Standard



Retail pharmacies will be identified by a value of A5 in the specialty code as received by the National Supplier Clearinghouse. Only DMERC suppliers with an A5 specialty code may use the NCPDP standard. The DMERCs, their EDI submitters, and their other trading partners are required to transmit the NDCs in the NCPDP standards for identification of prescription drugs dispensed through a retail pharmacy. NDCs replace the drug HCPCS codes for retail pharmacy drug transactions billed to DMERCs via the NCPDP standards.