(Medicare Claims Processing Manual)

Group Code: CO  CARC: 16  RARC: N56  MSN: N/A  100.9 - Non-Participating Physicians Who Elect the CAP   (Rev. 866, Issued: 02- 17-06, Effective: 07 -01-06, Implementation: 07- 03-06)  Participating CAP physicians must appeal drug administration denials.  For a non-participating physician that elects to participate in the CAP, he or she must agree to accept assignment for all CAP drug administration charges to allow for the Medicare bene ficiarys and approved CAP vendors appeal rights.  A/B MACs (B) shall pay all HCPCS codes that provide payment for the administration of CAP drugs on an assigned basis.  101 - The Competitive Acquisition Program (CAP) for Drugs and Instructions on Special CAP Appeals Requirements and Delivery of Dispute Resolution Services  (Rev. 1076, Issued:  10- 13-2006; Effective:  07- 01-06; Implementation:  11- 13-06)  All appeals of denied CAP claims will be processed by the local A/B MAC (B).  This includes an appeal for the denial of an approved CAP vendors drug product claim.  This break from the traditional administrative appeals process is necessitated by the arrangement whereby the CAP designated A/B MAC (B) pays the approved CAP vendor claim only after a match is found in the central claims processing system indicating the corresponding partici pating CAP physicians drug administration claim was paid by the local A/B MAC (B).  As a result, the only appealable issues attach to the decision of the local A/B MAC (B).   The CAP claims processing arrangement departs from the standard Part B claims processing routine.  The A/B MAC (B) will make an initial determination on whether the participating CAP physicians claim for drug administration is payable by applying local coverage determinations (LCDs) to the administration and to the drugs billed as no- pay on the claim.  If the A/B MAC (B) finds the no- pay or administration lines are contrary to the LCDs, it will deny the administration and pass on a non- approved indicator on the no-pay lines.  The A/B MAC (B) sends a pay process indicator to CWF for each of the no-pay lines.  When the designated A/B MAC (B) enters the vendor claim into the system, CWF looks for a match.  When CWF goes to find the match, it will not match aga inst non-approved lines.  If it finds a match among the approved lines, then it lets the designated A/B MAC (B) know and the claim is paid.  If it doesnt find a match, the claim recycles for 90 days.  Periodically during the 90 days, the designated A/B MA C (B) looks for a match again.  If it finds one, the claim pays.  If after 90 days it doesn't find a match, then the claim denies.  The A/B MAC (B) will notify CWF whether the approved CAP vendors claim for the drug is payable.  If the vendors claim is not payable because of a determination of the A/B MAC (B), then the designated A/B MAC (B) will be notified.  In turn, the designated A/B MAC (B) will deny the approved CAP vendors claim.  The claims processing requirements for this process have been descr ibed in previous CAP Change Requests.  Because the A/B MAC (B)s initial determination on the drug administration claim decides the outcome of the of the approved CAP vendors drug product claim, CMS  interprets the initial determination to be an initial determination of the approved CAP vendors drug product claim for the purposes of the Part B appeals regulations found at 42 CFR 405.801.  Accordingly, the approved CAP vendor shall not file its appeal with the CAP designated A/B MAC (B).  Rather, the approved CAP vendor shall file its appeal with the A/B MAC (B), with one exception.  That exception is the case where the approved CAP vendors drug product claim was denied because there was no matching claim filed by the participating CAP physician after 90 days of recycling.  In this instance, the designated A/B MAC (B) will deny the approved CAP vendors drug product claim and suppress appeal rights.  The remittance notice will instruct the approved CAP vendor that it may request a reopening.  Upon receipt of a reopening request, the designated A/B MAC (B) will contact the participating CAP physician and request that he or she fulfill his or her CAP participation agreement by filing the drug administration claim.  If the participating CAP physician does not follow through as required, then the designated A/B MAC (B) will initiate the dis pute resolution track discussed below.  In the role of the furnishing Medicare supplier, the approved CAP vendor is a party to any appeal of a denied drug administration claim filed by a participating CAP physician with the A/B MAC (B).  The balance of the rules pertaining to the A/B MAC (B)s adjudication of Part B appeals applies (See Pub. 100- 04, Chapter 29), with the following exceptions:   a) The A/B MAC (B) will check for duplicate appeals.  If the participating CAP physician and the approved CAP vendor filed independent appeals connected with the same service, then the A/B MAC (B) will merge the two files.   b) The A/B MAC (B) will ensure the approved CAP vendor is copied on all correspondence connected with the participating CAP physicians appeal of the denied drug administration claim.  101.1 - Dispute Resolution Services for Vendors (Rev. 1076, Issued:  10- 13-2006; Effective:  07- 01-06; Implementation:  11- 13-06)  The CAP designated A/B MAC (B) has responsibility to deliver dispute resolution services to the approved CAP vendor when the approved CAP vendors drug product claims are not paid because the participating CAP physician has either failed to file a payable drug administration claim or has failed to file a successful appeal of the denie d drug administration claim.   The approved CAP vendor may file its drug product claim on the day it delivers the drug to the participating CAP physician.  The participating CAP physician is contractually obligated to file his or her CAP drug administration claim within 14 days of admin istering the drug.   The approved CAP vendor may determine its own threshold for financial exposure.  If the approved CAP vendor does not receive payment within 14 days, then the approved CAP vendor may request assistance from the CAP designated A/B MAC (B) in encouraging the participating CAP physician to fulfill his or her contractual obligations.  If the CAP designated A/B MAC (B)s dispute resolution services do not yield adequate results for the approved CAP vendor, then the approved CAP vendor may request that the CAP des ignated A/B MAC (B) investigate the participating CAP physicians performance and recommend that the participating CAP physicians CAP election agreement be terminated.  If the CAP designated A/B MAC (B) does recommend termination, then a suspension, heari ng, and final termination process set forth in 42 CFR 414.916 will be employed by CMS.   101.2 - Dispute Resolution Services for Physicians (Rev. 1076, Issued:  10- 13-2006; Effective:  07- 01-06; Implementation:  11- 13-06)  If a participating CAP physician has an issue concerning the quality or safety of the services and/or drug delivered by the approved CAP vendor, then the participating CAP physician should address that issue through the approved CAP vendors grievance process.  If the participating CAP physician is not satisfied with the results of the approved CAP vendors grievance process, then the participating physician may ask the CAP designated A/B MAC (B) to review the situation and encourage the approved CAP vendor  to comply with its contractual obligations.  If the approved CAP vendor refuses to comply with its contractual CAP obligations, then the CAP designated A/B MAC (B) may recommend to CMS that the approved CAP vendors participation in CAP be terminated.  If  the CAP designated A/B MAC (B) does recommend termination, then a suspension, hearing, and final termination process set forth in 42 CFR 414.917 will be employed by CMS.  101.3 - Dispute Resolution Services for Beneficiaries  (Rev. 1076, Issued:  10- 13-2006; Effective:  07- 01-06; Implementation:  11- 13-06)