Competitive Acquisition Program (CAP) for Part B Drugs & Biologicals Training for Supplemental Insurance Companies August 2007
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1 Competitive Acquisition Program (CAP) for Part B Drugs & Biologicals Training for Supplemental Insurance Companies August 2007
2 DISCLAIMER This information release is the property of Noridian Administrative Services, LLC (NAS). It may be freely distributed in its entirety but may not be modified, sold for profit or used in commercial documents. The information is provided as is without any expressed or implied warranty. While all information in this document is believed to be correct at the time of writing, this document is for educational purposes only and does not purport to provide legal advice. All models, methodologies and guidelines are undergoing continuous improvement and modification by NAS and the Centers for Medicare & Medicaid Services (CMS). The most current edition of the information contained in this release can be found on the NAS web site at and the CMS web site at The identification of an organization or product in this information does not imply any form of endorsement.
3 Agenda Background Basics of Part B Drug & Biologicals Program List of CAP drugs Tax Relief & Healthcare Act of 2006 Flowchart of Program Claims Processing How will Coordination Of Benefits Contractor process the claims? References 3
4 Background Medicare Prescription Drug Improvement and Modernization Act of 2003 (MMA) Section 303(d) Competitive Acquisition Program for Part B Drugs and Biologicals No relation to Part D (PDP) Vendors Bid and are selected Physicians elect into CAP 4
5 Basic CAP Information CMS Change Requests Major CRs: 4064, 4309, , 4404, 5079, 5207, 5259, 5546, 5579 & 5658 Designated Carrier vs. Local Carrier Vendors Submits CAP Drug Claims to Designated Carrier (Noridian Administrative Services, LLC) Physicians Submit Claims to Local Carrier (That is the carrier that processes the physicians Part B claims) 5
6 CAP Drugs Includes approximately 190 injectable and infused Part B drugs most commonly provided by physicians incident to an office visit List of CAP drugs on the CMS website: Downloads/CAPDrugList.pdf 6
7 Tax Relief and Health Care Act of 2006 Congressional Passage of Amendment to CAP Legislation December 2006 Changes claims payment system for CAP drugs From a matching procedure (physician's drug administration claim is matched to a vendor s drug claim) Up front payment for vendors drug claims with post pay review 7
8 Tax Relief and Health Care Act of 2006 [2] The post pay review process Intended to assure that payment for a drug or biological is made only if the drug or biological has been administered to a beneficiary May include the use of statistical sampling Overpayments shall be recouped, offset or otherwise collected 8
9 Tax Relief and Health Care Act of 2006 [3] Post pay process applies to payment for CAP drugs supplied On or after July 1, 2006 and before April 1, 2007 for claims that are unpaid as of April 1, 2007 On or after April 1,
10 CAP Claim Submission - Vendor Claims received on or after April 1, 2007 will be no longer be held for 90 days searching for a match on the prescription order number Claims will be subject to post payment review and local carrier editing for possible denial for non coverage and medical necessity (CMS Change Request 5546) 10
11 Terms of Agreement for Participating in CAP [2] See the CAP Physician Election Agreement for more information the form is located in the downloads section of the CMS website page Bios/02_infophys.asp 11
12 Designated Carrier (NAS) - Receives Drug claim from Approved CAP Vendor Note: The following billing example is for illustrative purposes only. The loops and segments indicated on this slide are for supplemental insurance companies only. Q103J1745AZ V589 Vendor Receives Payment for HCPCS code J HCPCS Maps to Loop 2430 SVD03-2 with SVD03-1 = HC 12
13 Claim Processing - Local Carrier Receives Drug Administration and a No Pay Line from Physician Note: The following billing example is for illustrative purposes only. The loops and segments listed on this slide are for supplemental insurance companies only. Q103J1745AZ117 RX order number maps to Loop REF02 where REF01=XZ On the professional claim 7102 V589 No Pay/HCPCS Line Physician does not receive payment for - maps to Loop 2430 SVD03-2 with SVD03-1 = HC J1745 J Modifiers map to Loop 2430 SVD03-3, SVD03-4, SVD03-5 and SVD
14 What will the Crossover Companies do with the No Pay line? Do Not Pay the physician's HCPCS code/no pay line that contains a J1 or both J1 and J2 CAP modifiers Message code that is crossed over on the HCPCS code/no pay line is CO B20 The CAP Vendor is paid by the Designated Carrier for the HCPCS code/no pay line Lines with J3 or M2 modifiers are payable outside the CAP and therefore are eligible for supplemental payment 14
15 Reference CMS Website: rbios/02_infophys.asp#topofpage Example on next slide 15
16 16
17 Reference NAS Website Example on next slide 17
18 18
19 CAP Reminders Do not pay the No Pay Line HCPCS code (The approved CAP vendor receives reimbursement for that portion) Message code that is crossed over on the HCPCS code/no pay line is CO B20 Process the administration/office visit portion as normal 19
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