evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
The A/B MACs (B) shall manually add any additional practice/shipping addresses and the mailing/correspondence address to the spreadsheet provided to them by the shared system before sending the information to the designated A/B MAC (B).  A/B MACs (B) shall  also remove any members of a group practice who do not qualify to provide services under the CAP.  In order to qualify to provide services under the cap the providers must have prescriptive authority in their state to prescribe medications.  Examples of provider types that may or may not have prescriptive authority in their states are nurse practitioners and physicians assistants.  Since group practices must commit as a practice to enroll in the CAP program if they bill using the groups PIN, if the A/B MAC (B) receives from the shared system names of providers in a group for whom an election form has not been received, they shall contact the group practice to verbally request the required election form information.  A/B MACs (B) shall only remove names from the CAP provider table when it has been determined that the physician is no longer a member of a group practice.  A/B MACs (B) s hall not allow a group practice to participate in the CAP until all election information has been obtained for each eligible practice member within that group who bills using the groups PIN.  The designated A/B MAC (B) shall transmit information to each vendor on the physicians and practitioners who have elected that particular vendor 30 days prior to the start of the CAP year.   100.1.1.1 - Quarterly Updates (Rev. 866, Issued: 02- 17-06, Effective: 07 -01-06, Implementation: 07- 03-06)  On a quarterly basis, CMS may provide updates to the HCPCS codes that the participating CAP physician must accept for the CAP.  A/B MACs (B) must add these HCPCS codes to the table created in 100.1.1 by 7 days after receipt of the changes from CMS.   100.1.2 - Format for Data  (Rev. 866, Issued: 02- 17-06, Effective: 07 -01-06, Implementation: 07- 03-06)
(Medicare Claims Processing Manual)
100.1.2 - Format for Data  (Rev. 866, Issued: 02- 17-06, Effective: 07 -01-06, Implementation: 07- 03-06)  In order to simplify the transfer of physician election information, prior to end of the election period, the A/B MACs (B) and the designated A/B MAC (B) shall determine a common format in which to send the information to the designated A/B MAC (B).  This format shall remain constant for subsequent years unless CMS issues instructions that it is to be changed.    100.1.3 - Physician Information for the Vendors  (Rev. 866, Issued: 02- 17-06, Effective: 07 -01-06, Implementation: 07- 03-06)  One month before the beginning of the calendar year, the designated A/B MAC (B) shall transmit the following information to each vendor on the physicians who have elected that particular vendor:  the name, the street address, city, state, zip code, and phone number of each practice address/shipping address (physical location where the drugs will be administered), UPIN (or NPI when effective), e -mail address (if available) of the physicians who have elected to participate in CAP with that vendor and the drugs they have chosen.  If the mailing/correspondence address (where the participating CAP physician can be contacted directly) is different from the practice/shipping address, the mailing/correspondence shall be included.  If the group or individual practice  has more than one practice location where drugs are administered, each practice address/shipping location where drugs will be administered shall also be included.  ( NOTE:  For the 2006 claims processing period, the information must be sent by June 1, 2006).   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.
(Medicare Claims Processing Manual)
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
(Medicare Claims Processing Manual)
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).
(Medicare Claims Processing Manual)
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.
(Medicare Claims Processing Manual)
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.
(Medicare Claims Processing Manual)
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.
(Medicare Claims Processing Manual)
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)  As part of their normal data analysis, A/B MACs (B) shall monitor these claims submitted with the J2, restocking modifier, or J3, the furnish as written modifier, for  patterns of abuse and follow the Progressive Corrective Action (PCA) process described in the Program Integrity Manual, Chapter 3, Section 11.  100.2.8 - Claims Submitted for Only Drugs Listed on the Approved CAP Vendors Drug List  (Rev. 3721, Issued: 02- 24-17, Effective: 05 -25-17, Implementation: 05- 25-17)
(Medicare Claims Processing Manual)
The A/B MAC (B) shall edit to verify that the no -pay lines (lines with the CAP drug HCPCS code and the J1modifier) that the participating CAP physician has billed is for a drug included in the CAP and is from the particular CAP vendor they have chosen to receive drugs from.   If the A/B MAC (B) determines that the physician has billed no -pay lines along with the codes for the payment of the administration for drug HCPCS code(s) that are not provided by the approved CAP vendor that the physician had selected, it shall return as unprocessable those no- pay lines along with the lines for the codes for the payment of the administration for these drugs.  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: 7.8  100.2.9 - Submission of Claims With the Modifier JW, Drug Amount Discarded/Not Administered to Any Patient  (Rev. 1313; Issued:  07- 23-07; Effective/Implementation Dates:  08 -23-07)  The JW modifier must not be used on Medicare Part B Drug CAP claims; providers shall not code for wastage for drugs furnished under the CAP.  Claims for drugs provided under CAP submitted with the JW modifier will be treated as unprocessable.  100.2.10 - MSP Situations Under CAP  (Rev. 1088, Issued: 10- 27-06, Effective: 01 -01-07, Implementation: 01- 02-07)  Drugs Obtained Through the CAP for Beneficiaries With Insurance Primary to Medicare   Providers who elect into the CAP voluntarily agree to obtain CAP drugs for Medicare beneficiaries exclusively through an approved CAP vendor.  In situations where participating CAP providers obtain a drug from the CAP vendor for a beneficiary who is incorr ectly determined to have Medicare as their primary insurer, but the provider and the  CAP vendor must first bill the appropriate primary insurer for the drug and the administration service.
(Medicare Claims Processing Manual)
Upon receipt of the primary insurers payment, MSP claims should then be submitted by the physician to their A/B MAC (B) for the administration service and by the approved CAP vendor to the CAP designated A/B MAC (B) for the drug.  Providers are required t o submit MSP claims even if they believe there is no outstanding balance due.  Such claims must adhere to CAP guidelines and include the drug HCPCS code, the prescription number provided by the approved CAP vendor and an appropriate CAP no- pay modifier.  Approved CAP vendor claims must also adhere to CAP requirements and include the assigned prescription number.  All participating CAP providers to submit MSP claims for drug administration services where the drug was obtained from the approved CAP vendor.  Failure to submit an MSP claim for the drug administration prevents the processing of the vendors MSP claim by the CAP designated A/B MAC (B).  Drugs Obtained Outside of the CAP for Beneficiaries With Medicare   In certain rare situations, participating CAP providers may mistakenly obtain drugs for Medicare beneficiaries outside of the CAP vendor because they had determined that the beneficiary had another insurer that was primary to Medicare.  In order to make an appropriate payment for drugs administered under these unusual circumstances, we are allowing temporary use of the J3 modifier to bypass CAP edits and pay the participating CAP provider at the current ASP rate.   We have requested a modifier for use in this rare situation.  A/B MACs (B) will be notified through the usual quarterly update process when a new modifier is available.  At that time, the J3 modifier will no longer be accepted for this purpose.   As we expect the situations that require this modifier to be infrequent, A/B MACs (B) have the ability to review claims with this modifier to monitor for proper use and educational opportunities.  MSP Claims For Drugs Present on the Providers CAP Drug List   In order to prevent processing errors for MSP claims where the drug billed on the providers claim is present on the selected CAP drug list, A/B MACs (B) are to implement a SCF rule allowing an override of the CAP claims processing edits.  This SCF rule wi ll allow claims to be identified as MSP and not require the CAP modifiers or prescription number.
(Medicare Claims Processing Manual)
100.3 - Application of Local Medical Review Policies  (Rev. 866, Issued: 02- 17-06, Effective: 07 -01-06, Implementation: 07- 03-06)   A/B MACs (B) and/or Program Safeguard Contractors shall apply all Local Coverage Determination (LCD) policies and National Coverage Determination (NCD) policies to the administration and no- pay drug code lines on the CAP claims.  Should it be determined that a drug administration or drug code service line does not meet the requirements of the LCD, the A/B MAC (B) shall follow current processes to determine how to adjudicate the related services.   If appropriate, the A/B MACs (B) shall include messages on the MSN and RA to indicate which LCD was applied.   The A/B MACs (B) shall also apply all regular edits to the administration and no- pay drug lines and send appropriate denial messages.   100.4 - Claims Processing Instructions for the Designated A/B MAC (B)  (Rev. 866, Issued: 02- 17-06, Effective: 07 -01-06, Implementation: 07- 03-06)  The designated A/B MAC (B) shall follow normal procedures to enroll the Drug Vendors as provider specialty type, 95, Competitive Acquisition Program (CAP) for Part B Drug Vendors.   A separate 4 position, alpha -numeric vendor identification number (VIN) shall be assigned to be used in the prescription number and a master list of which numbers are assigned to which vendors shall be kept.  The designated A/B MACs (B) shall forward the VIN to the A/B MACs (B) and to CMS 14 days after new CAP vendor contractors have been announced by CMS.  CMS will post the VIN on the CMS Web site.  A/B MACs (B) shall download these identification codes from t he CMS Web site and added them to the A/B MAC (B)s table.  For subsequent CAP years, this date will be the first Monday in November.  These codes shall be added to the A/B MACs (B)s table by 14 days after receipt.