(Medicare Claims Processing Manual)

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)  The approved CAP vendor is not permitted to bill the beneficiary for any coinsurance or deductible until the approved CAP vendors drug product claim has been paid by the designated A/B MAC (B).  If the approved CAP vendor does bill the beneficiary before payment on the drug claim has been received, or if the approved CAP vendor bills the beneficiary too much after the drug product claim has been paid, then the beneficiary may use the approved CAP vendors grievance process to challenge the inappropriate billing.  If the approved CAP vendors grievance process does not yield satisfactory results for the beneficiary, then the beneficiary may ask the CAP designated A/B MAC (B) to counsel the approved CAP vendor on its contractual CAP obligations.  Transmittals Issued for this Chapter  Rev #  Issue Date  Subject  Impl Date  CR#  R12201CP  08/10/2023 Annual Clotting Factor Furnishing Fee Update 2024  01/02/2024 13313 R12067CP  06/02/2023 New Claims Modifier Requirement for Drugs and Biologicals from a Single -Dose Container or Single -Use Package  07/03/2023 13056 R12013CP  05/02/2023 Inflation Reduction Act Section 11407: Limitations on Monthly Coinsurance and Adjustments to Supplier Payment Under Medicare Part B for Insulin Furnished Through Durable Medical Equipment (DME)  IMPLEMENTATION NO LONGER SENSITIVE  07/03/2023 13014 R11917CP  03/21/2023 Inflation Reduction Act Section 11407: Limitations on Monthly Coinsurance and Adjustments to Supplier Payment Under Medicare Part B for Insulin Furnished Through Durable Medical Equipment (DME)  IMPLEMENTATION-  Rescinded and replaced by Transmittal  12013 07/03/2023 13014 R11834CP  02/02/2023 Inflation Reduction Act Section 11407: Limitations on Monthly Coinsurance and Adjustments to Supplier Payment Under Medicare Part B for Insulin Furnished Through Durable Medical Equipment (DME)  IMPLEMENTATION  NO LONGER SENSITIVE - Rescinded and replaced by Transmittal  11917 07/03/2023 13014 R11764CP  12/22/2022 New Medicare Part B Immunosuppressant Drug Benefit (PBID)  Implementation  01/03/2023 12804 R11646CP  10/19/2022 New Medicare Part B Immunosuppressant Drug Benefit (PBID)  Implementation  - Rescinded and replaced by Transmittal 11764 01/03/2023 12804 R11596CP  09/13/2022 Annual Clotting Factor Furnishing Fee 01/03/2023 12860  Rev #  Issue Date  Subject  Impl Date  CR#  Update 2023  R11567CP  08/18/2022 Annual Clotting Factor Furnishing Fee Update 2023- Rescinded and replaced by Transmittal 11596 01/03/2023 12860 R11427CP  05/20/2022 Claims Processing Manual Update -  Pub. 100.04 for Elimination of Certificates of Medical Necessity (CMNs) and Durable Medical Equipment Forms (DIFs)  01/03/2023 12734 R11414CP  05/12/2022 Claims Processing Manual Update -  Pub. 100.04 for Elimination of Certificates of Medical Necessity (CMNs) and Durable Medical Equipment Forms (DIFs) -  Rescinded and replaced by Transmittal 11427 06/13/2022 12734 R11140CP  12/02/2021 Update to the Internet Only Manual (IOM) Publication 100- 04, Chapters 3 and 17 01/04/2022 12525 R10329CP  08/28/2020 Annual Clotting Factor Furnishing Fee Update 2021  01/04/2021 11932 R10236CP  07/31/2020 Update to the IOM Publication (Pub) 100-04, Medicare Claims Processing Manual, Chapters 1, 6, 8, 17, 20, 22, 24, and 31 Referencing the Active Universal Resource Locators (URLs) for the Washington Publishing Company (WPC) and the ASC X12 Organizations, and Updates to the HIPAA Eligibility Transaction System (HETS)  08/31/2020 11857 R4384CP  08/30/2019 Annual Clotting Factor Furnishing Fee Update 2020  01/06/2020 11435 R4233CP  02/08/2019 Update to Publication (Pub.) 100- 04 Chapters 4 and 17 to Provide Language -Only Changes for the New Medicare Card Project  03/12/2019 11084 R4204CP  01/17/2019 January 2019 Update of the Hospital Outpatient Prospective Payment System (OPPS)  01/07/2019 11099  Rev #  Issue Date  Subject  Impl Date  CR#  R4186CP  12/31/2018 January 2019 Update of the Hospital Outpatient Prospective Payment System (OPPS)  Rescinded and replaced by Transmittal 4204  01/07/2019 11099 R4128CP  09/07/2018 Annual Clotting Factor Furnishing Fee Update 2019  01/07/2019 10918 R3932CP  12/08/2017 Special Requirements for Immunosuppressive Drugs  03/09/2018 10370 R3941CP  12/22/2017 January 2018 Update of the Hospital Outpatient Prospective Payment System (OPPS)  01/02/2018 10417 R3862CP  09/15/2017 Annual Clotting Factor Furnishing Fee Update 2018  01/02/2018 10254 R3856CP  09/01/2017 Clarification of the Billing of Immunosuppressive Drugs