(Medicare Claims Processing Manual)

For group practices that elect to participate in CAP, the individual UPINs (NPI when effective) shall be included.   Each year the date the designated A/B MAC (B) shall transmit information to each vendor on the physicians who have elected that particular vendor shall be 7 calendar days after the final date the A/B MACs (B) forward to the designated A/B MAC (B) the list of all the physicians who have elected to participate in CAP.  Should that date fall on a weekend, it shall be extended to the following Monday.  The designated A/B MAC (B) shall not send a vendor any information pertaining to other vendors.   100.2 - Claims Processing Instructions for CAP Claims for the A/B MACs (B)  (Rev. 1412, Issued: 01- 11-08, Effective: 01 -01-08, Implementation: 04- 07-08)  The A/B MAC (B) shall not process CAP claims submitted for United Mine Worker or Medicare Advantage or Railroad Board beneficiaries.  A/B MACs (B) shall follow normal procedures for the disposition of these claims.  A/B MACs (B) shall pay for the administration of the drugs for which physicians have elected to receive under CAP.  CAP claims are required to comply with Medicare rules and requirements for modifiers and other supporting information unless specific except ions are made.  The A/B MACs (B) shall process CAP claims from physicians per the following instructions.  100.2.1 - CAP Required Modifiers  (Rev. 3721, Issued: 02- 24-17, Effective: 05 -25-17, Implementation: 05- 25-17)   The A/B MAC (B) shall identify physicians who have elected CAP and will no longer pay the physician for drugs under the ASP system that were obtained through CAP.  A/B MACs (B) shall continue to pay physicians for the administration of CAP drugs.  Unless claims for the CAP drugs include the no- pay (J1), furnish as written (J3) modifier, or MSP (M2) modifier the claim will be denied.   When physicians submit a claim for a drug they have provided under the CAP without the J1, J3, or MSP modifiers, the contractor shall use the following remittance advice messages and associated codes when rejecting/denying claims under this policy. This CARC/RARC combination is compliant with CAQH CORE Business Scenario Three.   Group Code: CO  CARC: 96  RARC: N348  MSN: 7.7  A/B MACs (B) shall treat as unprocessable CAP claims with the following invalid modifier combinations on CAP claims:   J1 + J3 -  invalid  J2 without a J1 -  invalid  J2 + J3 -  invalid   A/B MACs (B) shall treat as unprocessable claims received with invalid modifier combinations.  The contractor shall use the following remittance advice messages and associated codes when rejecting/denying claims under this policy. This CARC/RARC combination is compliant with CAQH CORE Business Scenario Two.  Group Code: CO  CARC: 16  RARC: N519  MSN: N/A  100.2.2 - Submitting the Charges for the Administration of a CAP Drug and the No Pay Service Lines  (Rev. 866, Issued: 02- 17-06, Effective: 07 -01-06, Implementation: 07- 03-06)  No pay service lines are identified by the modifier code:  J1 -  Competitive Acquisition Program, no- pay submission for a prescription number.  On both paper and electronic claims, the physician must submit their charges for the administration of the CAP drug and an additional no- pay service line for each prescription number.  Each no- pay service line shall include the no- pay modifier J1, a HCPCS drug code, and a prescription number.  The J1 modifier should always be entered in the first modifier position.    The no- pay service lines shall be submitted with the regular billed charges for the administration of these drugs.  No payment shall be made for services received with the CAP no -pay modifier and they shall bypass the MSP Pay module.   100.2.3 - Submitting the Prescription Order Numbers and No Pay Modifiers  (Rev. 3721, Issued: 02- 24-17, Effective: 05 -25-17, Implementation: 05- 25-17)  On paper claims the prescription numbers must be entered in Item 19.  On electronic claims the prescription number must be entered at the line level in the ASC X12 837 professional claim format, LOOP 2410 REF02 (REF01=XZ) of the 5010 version.  As the Imple mentation Guide requires the entry of the National Drug Code (NDC) number in the LIN segment in order to enter the prescription number, the NDC will be required as well.  The NDC must be submitted in LOOP 2410 LIN03 (LIN02=N4).   The prescription number will consist of the vendor identification (ID) number, the HCPCS code, and the vendor controlled prescription number.  Each vendor controlled prescription number shall be a unique number and shall not consist of all zeros.   The standard system shall add the prescription number received on either paper or electronic claims to the claims screen and retain the information in history.  A/B MACs (B) shall forward the prescription number on both paper and electronic claims to CWF.  For paper claims, A/B MACs (B) shall return as unprocessable paper claims submitted with the J1 modifier, but no prescription number.   The contractor shall use the following remittance advice messages and associated codes when rejecting/denying claims under this policy. This CARC/RARC combination is compliant with CAQH CORE Business Scenario Two.  Group Code: CO  CARC: 16  RARC: N388  MSN: N/A  The standard system shall create a pre- pass edit to reject claims from physicians or practitioners submitted with a no -pay modifier on a line, but without a prescription number on that same line.  The contractor shall use the following remittance advice messages and associated codes when rejecting/denying claims under this policy. This CARC/RARC combination is compliant with CAQH CORE Business Scenario Two.  Group Code: CO  CARC: 16   RARC: N388  MSN: N/A  100.2.3.1 - Further Editing on the Prescription Order Number  (Rev. 3721, Issued: 02- 24-17, Effective: 05 -25-17, Implementation: 05- 25-17)  Prescription order numbers submitted with inappropriate spaces inserted disrupt the matching process between the physician/provider claims and the vendor claims.  Effective for claims processed on or after July 7, 2008, contractors shall implement edits to treat these claims as unprocessable.   Prescription order numbers submitted with less than 10 characters on CAP claims will also be treated as unprocessable.  For either of the two prior situations, the contractor shall use the following remittance advice messages and associated codes when rejecting/denying claims under this policy. This CARC/RARC combination is compliant with CAQH CORE Business Scenario Two.   Group Code: CO  CARC: 16  RARC: N388  MSN: N/A  In addition, CAP physicians/providers and CAP vendors may not submit new claims (processed as entry code 1) with prescription order numbers that they have already submitted on previously adjudicated claims, even if the prior claims have been denied.  The C AP physicians/providers and CAP vendors must request an adjustment to the original claim (processed as entry code 5).  C laims that have been returned as unprocessable may be accepted with the original prescription order number when resubmitted after being corrected.   CWF will create a new utilization error code that will be returned when it receives a claim that has a prescription order number on it that matches a prescription order number already on file from a different claim.  This claim could be from the same physi cian/provider/supplier or a different physician/provider/supplier.  CWF coding will differentiate between claims from the physicians/providers and claims from the CAP vendors.  It will be acceptable to allow a claim with a duplicate prescription order number as long as one claim is from a physician/provider and the other claim is from the vendor.  This will allow the prescription order number matching process to continue.   Contractors shall treat as unprocessable the entire claim when a claim receives the new CWF utilization error code.  Contractors shall not allow appeals rights on claims treated as unprocessable in response to the new error code.  The contractor shall use the following remittance advice messages and associated codes when rejecting/denying claims under this policy. This CARC/RARC combination is compliant with CAQH CORE Business Scenario Two.   Group Code: CO  CARC: 18  RARC: N389, M16 and N185 MSN: N/A  100.2.4 - CAP Claims Submitted With Only the No Pay Line  (Rev. 3721, Issued: 02- 24-17, Effective: 05 -25-17, Implementation: 05- 25-17)  Physicians must submit their charges for the administration of CAP drugs and the no- pay lines on the same claim.  A/B MACs (B) shall treat as unprocessable claims received that only have services submitted with the no- pay modifier.   The contractor shall use the following remittance advice messages and associated codes when rejecting/denying claims under this policy. This CARC/RARC combination is compliant with CAQH CORE Business Scenario Two.\   Group Code: CO  CARC: 16  RARC: M67  MSN: N/A  100.2.5 - Use of the Restocking Modifier  (Rev. 866, Issued: 02- 17-06, Effective: 07 -01-06, Implementation: 07- 03-06)  The restocking modifier is:  J2 -  Competitive Acquisition Program, (CAP) restocking of emergency drugs after emergency administration.  Under certain circumstances, physicians will be permitted to administer a drug they have on hand and go through the CAP program to restock it.  Once the participating CAP physician orders and receives the restocking drug from the approved CAP vendor, the physician will bill for the administration fee.  The physician will also include no -pay lines on the claim for each of the drugs as usual.  These lines will include the restocking modifier in addition to the no- pay modifier (in the first modifier position),  the procedure code for the drug, the prescription number and all other elements normally required.  A/B MACs (B) shall consider restocking drug claims for payment when the following requirements are met:   a) The physician has elected to receive the drug under CAP;   b) The physician has submitted the claim with the restocking modifier;   c) The physician received the drug from the CAP vendor to replace a drug he or she used from pre -existing stock.  d) The claim was submitted with the restocking modifier:   J2 - Competitive Acquisition Program, (CAP) restocking of emergency drugs after emergency administration.   By including the restocking modifier on the claim, the physician is asserting that:   a) The drug was required immediately;   b) The need couldnt be anticipated;   d) The drug was administered in an emergency situation; and  e) Documentation is being maintained in the file to validate the information in a -  d and will be made available to the A/B MAC (B) at their request.   100.2.6 - Use of the Furnish as Written Modifier  (Rev. 866, Issued: 02- 17-06, Effective: 07 -01-06, Implementation: 07- 03-06)  The furnish as written modifier is: J3 -  Competitive Acquisition Program, (CAP) drug not available through CAP as written, reimbursed under average sales price methodology.  When the J3 modifier is used, the physician will be allowed to bill Medicare for a CAP drug in addition to the claim for the administration of that drug.   A/B MACs (B) shall consider furnish as written drug administration claims for payment outside of the CAP program when the new furnish as written modifier is used.   By using only the J3 modifier on the claim, the physician is asserting that:   a) A specific drug product was medically necessary;   b) The selected drug vendor could not provide that specific brand and/or NDC for the CAP HCPCS code;   and  c) Documentation is being maintained on file to validate the information in a) and b) and will be made available to the A/B MAC (B) at their request.   100.2.7 - Monitoring of Claims Submitted With the J2 and/or J3 Modifiers  (Rev. 866, Issued: 02- 17-06, Effective: 07 -01-06, Implementation: 07- 03-06)