(Medicare Claims Processing Manual)

The designated A/B MACs (B) shall edit to determine if a UPIN, (or NPI when effective), of the ordering physician has been entered on the claim.  If the UPIN, (or NPI when effective), has not been entered on the claim, the designated A/B MAC (B) shall treat the claim as unprocessable.   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: 206  RARC: N265  MSN: N/A  100.4.5 - New MSN Message to Be Included on All Vendor Claims  (Rev. 866, Issued: 02- 17-06, Effective: 07 -01-06, Implementation: 07- 03-06)  On all vendor claims, whether paid or denied, the designated A/B MACs (B) shall include the following new Medicare Summary Notice Message:   Your physician participates in the Competitive Acquisition Program for Medicare Part B drugs (CAP).  The drug(s) you received in your physician's office were provided by an approved CAP vendor.  You will receive two separate Medicare Summary Notices (MSNs) .  This MSN is from the Medicare A/B MAC (B) that processes claims for your drug that came from the approved CAP vendor.  You will receive another MSN from the A/B MAC (B) that processes claims for your physician, for the administration of the drug(s).  If  you appeal the determination for this drug vendor claim, you must send your appeal to the A/B MAC (B) address listed on the physician administration MSN, and not this vendor claim MSN.  Spanish:   Su mdico participa en el Programa de Adquisicin Competitiva para las medicinas cubiertas por la Parte B de Medicare (CAP, por sus siglas en ingls).  Las medicinas que  usted recibi en la oficina de su mdico fueron provistas por un suplidor autorizado del CAP. Usted recibir dos Resmenes de Medicare por separado.  Este Resumen es de la empresa de seguros Medicare que procesa las reclamaciones de sus medicinas provistas  por el suplidor autorizado del CAP.  Usted recibir otro Resumen de la empresa de seguros Medicare que procesa las reclamaciones de su mdico, por el suministro de sus medicinas.  Si usted apela la decisin de esta reclamacin del suplidor de medicinas, d ebe enviar la apelacin a la empresa de seguros Medicare que se menciona en el Resumen de la reclamacin de su mdico y no a la direccin que aparece en este Resumen.   100.4.6 - Additional Medical Information  (Rev. 866, Issued: 02- 17-06, Effective: 07 -01-06, Implementation: 07- 03-06)  The designated A/B MAC (B) shall reserve the right to solicit, at any time, medical information to support adjudication of the drug vendors claim.   100.4.7 - CAP Fee Schedule  (Rev. 1055, Issued:  09- 11-06; Effective:  10 -01-06; Implementation:  10 -02-06)  CMS will provide a fee schedule for the payment of CAP drugs to the designated A/B MAC (B) and MCS.  The fees will be provided in a file on the CMS mainframe at a later date.  The file layout is attached.   CAP PROGRAM FEE SCHEDULE FILE RECORD DESCRIPTION   Field Name  Position  Length  Format  Description  HCPCS  1-5 5 Character  Healthcare Common Procedure Coding System  Filler  6-7 2  Space Filled  State  8-9 2 Character  Alpha Abbreviation  Filler  10-11 2  Space Filled  Current Year  12-15 4 Character  YYYY  Filler  16-17 2  Space Filled  Current Quarter  18 1 Character  Calendar Quarter - value 1 -4 Filler  19-20 2  Space Filled  Fee 21-29 9 Numeric  Fee to Pay For Drug $$$$$$(Pic9(6)v999)  Filler  30-80 51 Character  Space Filled   CMS will upload the CAP Part B Drug file to the Direct Connect each calendar quarter.  Approximately six weeks prior to the beginning of each calendar quarter (i.e., approximately 6 weeks prior to January 1, April 1, July 1, and October 1) an email will be sent out providing notification of the availability of the updated file.  The updated file will be available in the early November for the Ja nuary 1 release, early February for the March 1 release, early May for the July 1 release, and early August for the September 1 release.    100.5 - Matching the Physician Claim to the Vendor Claim  (Rev. 866, Issued: 02- 17-06, Effective: 07 -01-06, Implementation: 07- 03-06)  CWF shall match physician submitted claim lines with prescription numbers and no- pay modifiers to vendor submitted claim lines with prescription numbers.   The A/B MAC (B) shall send to CWF a pay/process indicator for each line of the claim, (including the lines with HCPCS codes for the administration of the CAP drug and the lines for the CAP drug HCPCS code), to indicate whether it is approved, not -payable d ue to medical necessity, or not payable due to a reason other than medical necessity.   When CWF finds a prescription number that matches a prescription number on the claim, it shall notify the designated A/B MAC (B).  The designated A/B MAC (B) shall make payment for the drug lines that have a pay/process indicator of approved.  It shall deny any lines not approved.   100.5.1 - Denials Due to Medical Necessity (Rev. 3721, Issued: 02- 24-17, Effective: 05 -25-17, Implementation: 05- 25-17)  If the lines are not approved due to medical necessity, 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: 50  RARC: N661  MSN: 16.48  100.5.2 - Denials For Reasons Other Than Medical Necessity  (Rev. 3721, Issued: 02- 24-17, Effective: 05 -25-17, Implementation: 05- 25-17)  If the designated A/B MAC (B) denies the lines due to other reason, 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: RARC most descriptive of other denial reason.  CARC 96 requires an accompanying RARC.  MSN: 16.10  100.5.3 - Changes to Pay/Process Indicators  (Rev. 866, Issued: 02- 17-06, Effective: 07 -01-06, Implementation: 07- 03-06)   Should A/B MACs (B) make adjustments to the physician claims, they shall forward any changes in the pay/process indicators to CWF and CWF shall make any changes to the pay/process indicator as necessary to keep it current.  CWF shall notify the designated A/B MAC (B) of any changes to the pay/process indicators so that they may respond accordingly.   100.5.4 - Post-Payment Overpayment Recovery Actions (Rev. 866, Issued: 02- 17-06, Effective: 07 -01-06, Implementation: 07- 03-06)  If it is determined on a post -pay basis that based on a change to the pay- process indicator the designated A/B MAC (B) has now made an overpayment, the designated A/B MAC (B) shall initiate an overpayment recovery action.  If it is determined that they hav e made an underpayment, they shall also take appropriate action.  A/B MACs (B) and the designated A/B MAC (B) shall follow the instructions in the Program Integrity Manual, Chapter 3 and the Medicare Financial Management Manual, Chapter 3, for overpayment recovery.   100.5.5 - Pending and Recycling the Claim When All Lines Do Not Have a Match  (Rev. 866, Issued: 02- 17-06, Effective: 07 -01-06, Implementation: 07- 03-06)  If the designated A/B MAC (B) receives a claim from the vendor and CWF determines some or all of the lines on the claim do not have a match, the designated A/B MAC (B) shall pend the claim for 90 days.  However, prior to the end of the 90 day period, if at  the vendors request the designated A/B MAC (B) can determine that a matching paper physician claim is on file, the designated A/B MAC (B) shall allow payment of the approved services on the claim.  The designated A/B MAC (B) may also recycle the claim back to CWF at their discretion to determine if a matching electronic claim has been received prior to the end of the 90 day period.  No interest shall be paid on the pending claim.  100.5.6 - Creation of a Weekly Report for Claims That Have Pended More Than 90 Days and Subsequent Action  (Rev. 3721, Issued: 02- 24-17, Effective: 05 -25-17, Implementation: 05- 25-17)  The shared system shall create a weekly report for the designated A/B MAC (B) providing information on claims that have pended for more than 90 days.  The designated A/B MAC (B) shall review the weekly report to identify and deny claim lines for which the 90 day time period has expired.  Before denying the claim lines, the designated A/B MAC (B) shall determine if the physician claim had been submitted as a paper claim.  If there is an approved physician paper claim for the beneficiary with the same HCPCS code and a date of service within 7 days of the date of service of the vendor drug claim posted at CWF and the details are not denied, the designated A/B MAC (B) shall pay the  claim lines.  If there is no claim on file that matches these criteria, or some details are denied, the designated A/B MAC (B) shall deny the corresponding claim lines.  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: 107  RARC: N/A  MSN: 21.21  100.6 - Coordination of Benefits  (Rev. 866, Issued: 02- 17-06, Effective: 07 -01-06, Implementation: 07- 03-06)  CWF and the designated A/B MAC (B) shall submit claims for full payment of drug claims to the Coordination of Benefits Contractor (COBC) for crossover to trading partners, in accordance with the requirements specified in Transmittal 138 (Change Request 3218).   100.7 - National Claims History  (Rev. 866, Issued: 02- 17-06, Effective: 07 -01-06, Implementation: 07- 03-06)  CWF shall pass the prescription number to National Claims History (NCH) where it will be stored.   100.8 - Adding New Drugs to CAP  (Rev. 866, Issued: 02- 17-06, Effective: 07 -01-06, Implementation: 07- 03-06)  The A/B MACs (B) s and the Designated A/B MAC (B) shall develop the capacity to manually add new vendor specific HCPCS codes and identify to which vendor lists these have been added for the table developed in 4064.1.1.2.1 on a quarterly basis upon notifica tion by CMS.  A/B MACs (B) shall add these codes to their table by 7 days after receipt of notification from CMS.   100.8.1 - Updating Fee Schedule for New Drugs in CAP  (Rev. 866, Issued: 02- 17-06, Effective: 07 -01-06, Implementation: 07- 03-06)  The Designated A/B MAC (B) shall develop the capacity to add the prices for the new vendor specified HCPCS codes to the pricing table.  Prices will be available on the CMS website for the quarterly update of prices to the of new drug prices.   100.8.2 - Changes to the List of Drugs Supplied by Approved CAP Vendors   (Rev. 1506; Issued:  05- 16-08; Effective Date:  10 -01-08; Implementation Date:  10-06-08)