evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
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.   The designated A/B MAC (B) shall track the name, the address, zip code, and phone number of each practice location/shipping address (location where the drugs will be administered), PIN, UPIN, (or NPI when effective), and e -mail (if available) of the physic ians and physician groups and which vendors and which drugs they have chosen.  In addition, the mailing/correspondence address (where the participating CAP physician can be contacted directly) for each physician shall also be tracked.  This information sha ll be made available to CMS upon request.  On a quarterly basis, the designated A/B MAC (B) shall manually add additional HCPCS codes to the information above when received from the A/B MACs (B).  They shall add this information by 14 days after its receipt from the A/B MACs (B).   The designated A/B MAC (B) shall only process CAP claims from approved drug vendors submitted in the ASC X12 837 professional claim format.  All vendor claims shall be processed by the designated A/B MAC (B).  These will not include claims for United Mine Worker, Railroad or Medicare Advantage beneficiaries.   100.4.1 - Creation of Internal Vendor Provider Files  (Rev. 3721, Issued: 02- 24-17, Effective: 05 -25-17, Implementation: 05- 25-17)  The designated A/B MAC (B) shall create an internal provider file for each vendor which includes the names, addresses, and UPINs, (NPI when effective), of those physicians who have elected that vendor.   The designated A/B MAC (B) shall edit incoming vendor claims to verify that the UPIN number on the claim for the ordering physician is one of the UPINs on the provider file for that vendor.  The designated A/B MAC (B) shall treat the claim as unprocessable  when it receives claims from vendors with ordering physician UPINs that do not match a physician UPIN on the provider file.
(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: N265  MSN: 9.7 and 17.11  100.4.2 - Submission of Paper Claims by Vendors  (Rev. 3721, Issued: 02- 24-17, Effective: 05 -25-17, Implementation: 05 -25-17)  The designated A/B MAC (B) shall treat as unprocessable paper claims submitted by vendors and 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: M117  MSN:  N/A  100.4.3 - Submission of Claims from Vendors With the J1 No Pay Modifier  (Rev. 3721, Issued: 02- 24-17, Effective: 05 -25-17, Implementation: 05- 25-17)  The designated A/B MAC (B) shall treat as unprocessable claims submitted by vendors with a 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: N265  MSN: 9.7 and 17.11  100.4.4 - Submission of Claims from Vendors Without a Provider Primary Identifier for the Ordering Physician  (Rev. 3721, Issued: 02- 24-17, Effective: 05 -25-17, Implementation: 05- 25-17)  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.
(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: 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:
(Medicare Claims Processing Manual)
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
(Medicare Claims Processing Manual)
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.
(Medicare Claims Processing Manual)
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)
(Medicare Claims Processing Manual)
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)
(Medicare Claims Processing Manual)
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)
(Medicare Claims Processing Manual)
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)  The CAP will be implemented with a single category of drugs and one geographic area, however as the program evolves, additional geographic areas and additional drug categories may be created.  Approved CAP vendors will also be able to request approval for changes to the lists of drugs that they supply under the CAP.  As CMS continues to develop the CAP, additional geographical areas and additional drug categories may be created.  If additional drug categories are created, certain drugs may appear in more than one drug category.   Approved CAP vendors will be permitted to request certain changes to the list of drugs that they supply under the CAP.  Beginning in July 2006 with changes to be effective October 1, 2006, approved CAP vendors may request that CMS (or its designee) approve  the following types of changes:    Substitution:   Approved CAP vendor may request approval to replace one or more drug products as identified by national drug codes (NDCs) in a Healthcare Common Procedure Coding System (HCPCS) code supplied by the approved CAP vendor with one or more NDCs.
(Medicare Claims Processing Manual)
 Add newly issued HCPCS Codes:  Approved CAP vendor may request that CMS allow it to supply additional drug products with new HCPCS codes under the CAP.    Additional NDCs:  Approved CAP vendor may request that CMS allow it to supply additional NDCs under a HCPCS code that the approved CAP vendor already supplies under the CAP.   Orphan Drugs:  Approved CAP vendor may request that CMS allowed it to supply single indication orphan drugs under the CAP.  Regulation text describing the above may be found at 42 CFR 414 Subpart K.  Changes to the drug list :  Written requests for changes to the approved CAP vendors drug list must be submitted to CMS and the CAP designated A/B MAC (B).  The requests must include a rationale for the proposed change, and a discussion of the impact on the CAP, including safety, waste, and potential for cost savings.  If approved, routine changes will become effective at the beginning of the following quarter.  CMS will post the changes on the CMS Web site:  http://www.cms.gov/Medicare/Medicare -Fee-for-Service- Part-B-Drugs/CompetitiveAcquisforBios/index.html    and notify the A/B MACs (B) and participating CAP physicians of any changes on a quarterly basis via a recurring Change Request (CR).  Physicians who participate in the CAP are required to obtain all CAP drugs on the updates from the approved CAP vendor  unless medical necessity requires the use of a formulation not supplied by the vendor.  Please note that approved  changes will apply only to the list of drugs supplied by the approved CAP vendor who submitted the request; therefore, each vendors drug list may contain different drugs after changes to the initial drug list are approved.
(Medicare Claims Processing Manual)
Timeline for changes :  There will be one timeline for the submission of changes to the approved CAP vendors drug list.  For new HCPCS and/or NDC codes, and substitutions or changes to NDC codes supplied under an existing HCPCS code, the approved CAP vendor will be required t o submit requests for drug list changes no later than four months before the beginning of the quarter in which the changes will take effect.  Updated tables listing the HCPCS codes under a specific vendors drug categories will be avail able 30 days prior to the start of the following quarter.  NDC number changes will not require associated table modifications and will not affect established payment amounts.  Physicians will be notified of these changes 30 days before the start of a quart er.  Price files incorporating these changes will be available 7 -14 days prior to the effective date for the corresponding changes.  An example of the timeline for the July 1, 2008 HCPCS and NDC code changes appears below.   Example of Timeline for HCPCS and NDC Additions   Date  Action  3/1/2008  Vendor deadline to submit request for new HCPCS and/or NDCs  3/12/2008  CMS begins approval process to evaluate vendor request  5/24/2008  HCPCS and/or NDC changes approved to become effective July 1, 2008  5/30/2008  Per the approval of all clearance processes, CMS issues a CR regarding approved drug list changes and tables that will become effective July 1, 2008  6/2/2008  Designated A/B MAC (B) downloads HCPCS changes to the drug table.  List posted onto the CMS Web site.  Physicians receive updated list of drugs from the CAP vendor.  6/5/2008  A/B MACs (B) shall acquire HCPCS changes from the Designated A/B MAC (B)  6/17-6/24/2008  Price file with new codes posted  7/1/2008  Effective date for additional HCPCS codes; beginning of next quarter
(Medicare Claims Processing Manual)
Payment amount :  The payment amount for new HCPCS codes added to an approved CAP drug vendors drug list will be ASP + 6%.  Addition or substitution of NDC numbers under an existing HCPCS code supplied by an approved CAP vendor will not change the CAP single payment amount for that HCPCS code.  CMS will update the single payment amount base d on the approved CAP vendors reported net acquisition costs for the category of drugs on an annual basis.  100.8.3 - CAP Not Otherwise Classified (NOC) Drugs  (Rev. 1034, Issued:  08- 18-06; Effective:  01 -01-07; Implementation:  01 -02-07)   As described in Section 100.8.2, approved CAP vendors are able to request approval for changes to the list of drugs that they supply under the CAP.  In an effort to improve beneficiary access to newly marketed drugs, approved CAP vendors will be able to request the addition of certain NOC drugs as defined by CMS to their drug lists for claims with dates of service on or after January 1, 2007.  The process for adding NOC drugs to an approved CAP vendors drug list will generally follow the process for adding new drugs to the CAP.  An approved CAP vendor is required to submit a written request to add specific NOC drugs to the CAP designated A/B MAC (B).  The request must include a rationale for the proposed change, and a discussion of the impact on the CAP, including safety, waste, and potential for cost savings.  The CAP designated A/B MAC (B) will review the application and forward the informatio n to CMS along with a recommendation for approval or denial.  CMS will make a final decision upon review of the application and the designated A/B MAC (B)s recommendation.  If approved, changes will become effective at the beginning of the following quart er.  CMS will post the approved NOC additions along with other changes to the CAP Drug List on the CMS Web site:  http://www.cms.gov/Medicare/Medicare -Fee-for-Service- Part-B-Drugs/CompetitiveAcquisforBios/index.html
(Medicare Claims Processing Manual)
Additions of NOC drugs apply only to the approved CAP vendor and the CAP category identified on the request.  Therefore, each vendors drug list may contain different drugs after changes to the initial drug list are approved.  The timeline for this process  follows the timeline for HCPCS code changes described in manual section 100.8.2.  CMS will also continue to notify A/B MACs (B) of any changes to the CAP drug list on a quarterly basis.  Participating CAP physicians will also be notified of changes at lea st 30 days before the approved changes will become effective.   The process to approve CAP NOC drugs differs from the process for other CAP drug approvals in two significant ways.  First, CMS will define a list of CAP NOC drugs that the approved CAP vendor must use when requesting the addition of NOC drugs to the CAP.  The CAP NOC drug list is based on the current ASP NOC list and is limited to drugs that are likely to fit the existing CAP drug category (or categories) and drugs that have a single national ASP -based payment amount.  The list of CAP NOC drugs will be posted on the CMS CAP Web site:  http://www.cms.gov/Medicare/Medicare -Fee-for-Service- Part-B-Drugs/CompetitiveAcquisforBios/index.html   and updated quarterly.  The CAP NOC drug payment amount is set at the rate published on the ASP NOC file consistent with the next quarterly update; the CAP NOC payment amount will be updated annually.  Second, physician administration claims and vendor drug claims for services related to CAP NOC drugs are required to use the CAP -specific Q -code for all CAP NOC drug claims along with the appropriate CAP modifiers.  This code is necessary to distinguish CAP NOC drug claims from ASP NOC claims and to provide payment for CAP NOC drugs within the CAP.  In addition to the use of the CAP NOC Q -code, CAP NOC claims must identify the specific NOC drug that had been administered.  All remaining  requirements concerning the proper submission of a claim continue to be effective, and claims processing for CAP NOC drug claims will follow procedures described in previous CAP CRs and applicable Manual sections.  All current editing for other NOC codes s hall also be applied to the CAP NOC code.