How long does it take for your pharmacy to get your Dex RX covered by Medicare? They assured me they have all the paperwork from my clinic, they have all the billing figured out but they say I cannot have my Dex sensors or transmitter until they hear from Medicare.
I had to transfer to a new supplier, and I’m wondering if they are slow or is it Medicare’s fault?
Also, do they cover strips for fingersticks in any way?
Thanks for any info.
I still do not have my RX Dexcom. The pharmacy/supplier said they sent everything to Medicare’s CGM department. If they indeed have a CGM review department, then their Medicare DME people don’t know about it. Whatever the case, no one at Medicare can see my paperwork anywhere and the supplier isn’t working to hard to figure out where the paperwork went.
Well I think they are a supplier but they say Medicare hasn’t approved. Medicare told me today they ought to call the number for providers and find out what the hold up is. Gee, that makes sense!
Medicare does NOT approve or disapprove anything. Medicare is a pay and chase service. They pay all claims submitted and then if claim is false they chase whoever it was paid to. To bill all suppliers just need to submit a claim. Many suppliers like Walgreens say that Medicare must approve when it is just their own company’s approval they must get. Medicare has NO approvals all they must do is submit a claim.
This is what the Medicare person was telling the supplier, in our three way call. However, who reviews the notes your doctor or clinic has to send to prove you need CGM? Or do they just need to be with the supplier?
She told the Medicare DME person there is a Medicare department set up for CGM review.
She also said Medicare is rejecting my claim and not paying it.
So I don’t know, and still I have nothing.
Have you gone to medicare.gov logged in and checked your claims? If there was a claim submitted and denied it would be there. If there is no claim for the cgm then it was not submitted to Medicare. You just have to make sure that you qualify for the cgm. Are you taking insulin? If so, you qualify, if not you are not qualified at this time. They are looking at making cgm’s available for all type 1 and type 2 diabetics but so far that has not been started. You can only qualify for a medicare cgm if you take insulin, be it short term or long term insulin. In a year or two they may have it expanded to all diabetics.
Yep Ive been type I for 53 years. I’m a veteran.
The supplier says they sent everything and Medicare does not have it. Now if they would follow up with the Provider line as Medicare suggested, maybe they could get this done. You would think they would have the time to do this, but still today nothing I can see. And no claim on Medicare on my Medicare dashboard. I chatted Walgreens corporate and the pharmacy there sees no reason for denial on my account.
@Laura_S If possible, try a different supplier. It looks like Walgreens is screwing things up, CGM should be covered as DME on Medicare Part B. My supplier is Edwards, they have never delayed or missed a CGM delivery. They send a 90 day refill by Fedex every 90 days.
Thats what a supervisor at Medicare suggested. She said all they need to do is call an 800 number specific to my state, and get things done. So far, they haven’t. It’s a very easy thing to do I guess.
Laura I’m sorry to hear you are having trouble getting your CGM. To answer one of your original questions I once had a DME supplier take more than 90 days to send me a new order that was paid for by employer insurance.
You also asked about who reviews the notes from the clinic. Medicare requires the DME vendor (Walgreens in your case) to keep documentation to prove you meet the Medicare requirements for having a CGM in case they (Walgreens) are audited by Medicare. I think, but I don’t know for sure, Medicare is checking for diagnoses codes for diabetes and an A1C test in the past 90 days when it processes the claim. Maybe Walgreens isn’t seeing the required codes and the reps should be saying “Medicare will deny” instead of “Medicare has denied”. Have the claims for your most recent doctors appointment and lab tests posted yet?
What changed that made you have to move your CGM order to Walgreens?
Please note that the people in your local Walgreens probably can’t call the Medicare 800 number. I would encourage you to go back in to the store, ask to speak with someone familiar with DME orders, which may mean going back when they are working, and walk though the whole thing with them. Are they processing it as DME? Is it coded correctly? If everything checks out ask them to call the Walgreens Medicare help desk while you wait.
I’m very grumpy over this. They have been trying to bill the portion Part B won’t pay to my old Medicaid card. I have QMB now and told them to use the new card issued from the Medicaid dept. Well they ignored me and are trying to bill the old card. BCBS Medicaid thinks that’s the issue because they see the denials happening. Grrr. I need a drink and I don’t drink.
That’ll do it. Congrats on finding what is wrong. Hope getting it fixed is easy.
If you are grumpy enough to find a different place to by CGMs after you finally get your 90 day supply from Walgreens here is my list of mail order vendors that sell Dexcom. Plug them into your plans provider search to see if any are in network. https://forum.tudiabetes.org/t/wanna-break-up-with-my-dexcom-supplier-tips/91572/21?u=spdif
Funny thing about not drinking, I don’t either, when I was first diagnosed at 13 the hospital CDE said life would be easier if I avoided it. After I wrote you I went to the grocery store to buy ingredients for a soup that includes vermouth. After 30 minutes of being mystified by alcohol labels I left without it. Yet another side effect of diabetes.
So I called a different location, got a supervisor who said they would call her to get things rolling. No response yet. And my CDE wrote me and said she would resend the records. I told her they have the records (I know she does her job always) and they have been running the wrong card. No one is calling me. So I may need to move my Omnipod and Dex orders to a new supplier. Thanks for the list. Very cute about the alcohol!
I’m using Aetna Silverscript Plus for pods so if I move, I wonder if any of these will run both Part D for those and B for Dex? Adapt health ( where I moved from) does both I think. Or will continue to sell me the old pods until they have no more in stock. Under part B.
CGM under regular Medicare is always going to be Part B. Medicare has certain requirements however to qualify you for one. I think pretty much if you are a Type 1 you qualify. But you do have to see your doctor within a 6 month period and there has to be proof you are a Type 1 or meet other criteria. Those can hold up approval and they don’t always pass that information on.
Sometimes a pharmacy enters a wrong number and no one wants to bother asking, changing or investigating why. Wrong card, wrong code etc, but it just sits there. Easiest path unfortunately. My local pharmacy did that one time, it just kept saying it wasn’t getting approved until I talked to someone that actually looked up what was going on and a proper Medicare code wasn’t being used. That also happened with a lab test at a lab, in that case the doctor sent in a wrong code.
But given if those are fine, I would try a different supplier. I like ADS. When I went on Medicare Dexcom recommended them and they took care of the whole process within a couple of weeks. Things change with companies but I don’t remember hearing any complaints about them. In my case they send me a 3 month supply and just text me when the time is coming up, do I need my supplies? I respond yes and they send them at the appointed time. It was, and is, a very easy process.
Omnipods under Medicare will always be Part D because of being a patch pump. Optum Rx handles the scripts for me and I get them through them.
I also recommend restarting Dexcom G6, that way you build a back up supply for delays like this.
I tried to reinstate my account at Adapt, much as I don’t like them. The girl said I can but she sees the Walgreens order sitting there and can’t run my order through Adapt until it’s gone. So I got on a Walgreens chat, and the pharmacist said it’s sitting there and not in any stage of processing. They won’t return my CDE’s calls, they told another Walgreens they were working on my case but are not, and they refused to return all my messages when I said y’all are simply using the wrong card and it’s gonna get denied. So I’ve had it. I had a real stress attack tonight after dealing with this part of last week and now all of this week. Thing is too, I am on QMB which pays anything Part B will not pay. So they’re not out of any money.
I think I have a transmitter somewhere, and I have a couple sensors left. But suppose I didn’t? This is not a game and this is not something that inept people should be in charge of.
BTW, Medicare doesn’t want anything except for them to have the records and this Walgreens person thinks Medicare has a department sitting there checking on CGM and a patient’s eligibility. Medicare DME supervisor said it’s not like that at all, we need a claim and they need to make the sale. Un Believable.
Laura, at least you know what the problem is regarding the different Medicare/ Medicaid cards. Hang in there! I know how frustrating it is talking to pharmacies… sometimes like talking to a brick wall. I get my Dexcom supplies through a Walgreens Community Center – which is different than a regular Walgreens store. I tried to use my local Walgreens (a couple of blocks from my house), but I had problems with EVERY ORDER. Then I called a Walgreens COMMUNITY store in my area. They had everything figured out within two hours. They no longer can ship supplies to me, but I have no problem driving a couple of miles each month to pick up what I need. I live in two states since I am a Snowbird, and I think that Walgreen Community stores have been a Godsend in both states. Worth a try…
BTW, Medicare will not pay for any bloodsticks as long as you are using either a G6 or a G7 since their advertising says that no finger sticks are needed. We all know that is not true, but Medicare seized on that loophole early on, and they refuse to pay for supplies that the manufacturer says are no longer needed.
Sending you good wishes, success with the quest, and hugs!
So I told them I was pulling my accounts on the voice mail and now the sensors are filled but the transmitter is not. I have no clue…
The local other stores (even one inside a hospital) wouldn’t help the other store do anything. Oh and I do use my Freestyle meter on my Eros PDM for Omnipod and a Next meter. I get strips for the latter for $30 for 70 strips on Amazon.
Trying to hold out hope for the transmitter…
