Department of Health & Human Services (DHHS) Centers for Medicare & Medicaid Services (CMS) Transmittal 3354 Date: September 18, 2015

Transcription

1 anual Pub edicare laims Processing epartment of ealth & uman ervices () enters for edicare & edicaid ervices () Transmittal 54 ate: eptember 8, 05 hange Request 95 UBJT: January 06 Quarterly verage ales Price (P) edicare Part B rug Pricing iles and Revisions to Prior Quarterly Pricing iles. URY O NG: The P methodology is based on quarterly data submitted to by manufacturers. will supply contractors with the P and not otherwise classified (NO) drug pricing files for edicare Part B drugs on a quarterly basis. Payment allowance limits under the OPP are incorporated into the Outpatient ode ditor (O) through separate instructions that can be located in hapter 4, section 50 of the O. T T: January, 06 *Unless otherwise specified, the effective date is the date of service. PLNTTON T: January 4, 06 isclaimer for manual changes only: The revision date and transmittal number apply only to red italicized material. ny other material was previously published and remains unchanged. owever, if this revision contains a table of contents, you will receive the new/revised information only, and not the entire table of contents.. NG N NUL NTRUTON: (N/ if manual is not updated) R=R, N=N, =LT-Only One Per Row. R/N/ PTR / TON / UBTON / TTL N/. UNNG: or edicare dministrative ontractors (s): The edicare dministrative ontractor is hereby advised that this constitutes technical direction as defined in your contract. does not construe this as a change to the tatement of ork. The contractor is not obligated to incur costs in excess of the amounts allotted in your contract unless and until specifically authorized by the ontracting Officer. f the contractor considers anything provided, as described above, to be outside the current scope of work, the contractor shall withhold performance on the part(s) in question and immediately notify the ontracting Officer, in writing or by , and request formal directions regarding continued performance requirements.. TTNT: Recurring Update Notification

2 ttachment - Recurring Update Notification Pub Transmittal: 54 ate: eptember 8, 05 hange Request: 95 UBJT: January 06 Quarterly verage ales Price (P) edicare Part B rug Pricing iles and Revisions to Prior Quarterly Pricing iles T T: January, 06 *Unless otherwise specified, the effective date is the date of service. PLNTTON T: January 4, 06. GNRL NORTON. Background: The P methodology is based on quarterly data submitted to by manufacturers. will supply contractors with the P and not otherwise classified (NO) drug pricing files for edicare Part B drugs on a quarterly basis. Payment allowance limits under the OPP are incorporated into the Outpatient ode ditor (O) through separate instructions that can be located in hapter 4, section 50 of the O. B. Policy: ile: January 06 P and P NO -- ffective ates of ervice: January, 06, through arch, 06 ile: October 05 P and P NO -- ffective ates of ervice: October, 05, through ecember, 05 ile: July 05 P and P NO -- ffective ates of ervice: July, 05, through eptember 0, 05 ile: pril 05 P and P NO -- ffective ates of ervice: pril, 05, through June 0, 05 ile: January 05 P and P NO -- ffective ates of ervice: January, 05, through arch, 05. BUN RQURNT TBL "hall" denotes a mandatory requirement, and "should" denotes an optional requirement. aintainers 95. The January 06 and, if released, the revised October 05, July 05, pril 05, and January 05, P drug pricing files for edicare Part B drugs will be available via the ata enter () ontractors shall download the January 06 P drug pricing file through the on or after ecember 6, 05.

3 aintainers ontractors shall retrieve the January 06 P NO pricing file from the P webpage on or after ecember 6, ontractors shall use the January 06 P and NO drug pricing files to determine the payment limit for claims for separately payable edicare Part B drugs processed or reprocessed on or after January 4, 06 with dates of service January, 06, through arch, ontractors shall use the January 06 P drug pricing file to update the drug payment limits for claims for infusion drugs furnished through a covered item of processed or reprocessed on or after January 4, 06, with dates of service on or after January, f released by, contractors shall download the revised October 05 P drug pricing file through the on or after ecember 6, 05. U00.@B90.P.R.Y5.OT f released by, contractors shall overlay or manually update the previous October 05 file with the new October 05 P drug pricing file f released by, contractors shall use the revised October 05 P drug pricing file to determine the edicare Part B drugs processed or reprocessed on or after January 4, 06 with dates of service October, 05, through ecember, f released by, contractors shall retrieve the revised October 05 P NO pricing file from the P webpage on or after ecember 6, f released by, contractors shall use the revised October 05 P NO pricing file to determine the edicare Part B drugs processed or reprocessed on or

4 aintainers after January 4, 06 with dates of service October, 05, through ecember, f released by, contractors shall download the revised July 05 P drug pricing file through the on or after ecember 6, 05. U00.@B90.P.R.Y5.JUL f released by, contractors shall overlay or manually update the previous July 05 file with the new July 05 P drug pricing file f released by, contractors shall use the revised July 05 P drug pricing file to determine the edicare Part B drugs processed or reprocessed on or after January 4, 06 with dates of service July, 05, through eptember 0, f released by, contractors shall retrieve the revised July 05 P NO pricing file from the P webpage on or after ecember 6, f released by, contractors shall use the revised July 05 P NO pricing file to determine the edicare Part B drugs processed or reprocessed on or after January 4, 06 with dates of service July, 05, through eptember 0, f released by, contractors shall download the revised pril 05 P drug pricing file through the on or after ecember 6, 05. U00.@B90.P.R.Y5.PR f released by, contractors shall overlay or manually update the previous pril 05 file with the new pril 05 P drug pricing file. f released by, contractors shall use the revised pril 05 P drug pricing file to determine the edicare Part B drugs processed or reprocessed on or

5 aintainers after January 4, 06 with dates of service pril, 05, through June 0, f released by, contractors shall retrieve the revised pril 05 P NO pricing file from the P webpage on or after ecember 6, f released by, contractors shall use the revised pril 05 P NO pricing file to determine the edicare Part B drugs processed or reprocessed on or after January 4, 06 with dates of service pril, 05, through June 0, f released by, contractors shall download the revised January 05 P drug pricing file through the on or after ecember 6, 05. U00.@B90.P.R.Y5.JN f released by, contractors shall overlay or manually update the previous January 05 file with the new January 05 P drug pricing file f released by, contractors shall use the revised January 05 P drug pricing file to determine the edicare Part B drugs processed or reprocessed on or after January 4, 06 with dates of service January, 05, through arch, f released by, contractors shall retrieve the revised January 05 P NO pricing file from the P webpage on or after ecember 6, f released by, contractors shall use the revised January 05 P NO pricing file to determine the edicare Part B drugs processed or reprocessed on or after January 4, 06 with dates of service January, 05, through arch, ontractors shall not search and adjust claims that have already been processed unless brought to their attention.

6 aintainers 95. Notification of successful receipt shall be sent via e- to stating the name of the file received and the entity for which it was received (e.g., carrier/ /fiscal intermediary name and number) The P and NO drug pricing files will contain the applicable payment allowance limits (i.e., 06% P, 06%, or 95% P); therefore, edicare contractors shall not make any additional payment calculations or any drug or biological not listed in the P or NO drug pricing files, contractors shall determine the payment allowance limits in accordance with the policy described in the edicare laims Processing anual, hapter 7, ection Part shall seek payment allowances not on the P file from their local carrier for drugs and biologicals ontractors shall use the most current version available of the edicare ontractor Reporting Template for Part B drugs to report information on edicare Part B drugs not paid on a cost or prospective payment basis when payment limits are not listed in the quarterly drug pricing P and NO files, or in the OPP Pricer ontractors shall use the template to report pricing information for the NO drugs not included on the edicare Part B NO pricing file, any P drug codes not on the P file, and OPP drugs not in the OPP Pricer ontractors shall list all drugs that were priced since the last submitted report ontractors shall list each drug priced on the only once. report or compounded drugs, contractors shall report the name of each drug in the compounded product ontractors shall prepare and submit the reports so that each report covers approximately 0 days of

7 aintainers pricing activity ontractors shall report drugs omitted from previous reports in the next report ontractors shall complete the report in its entirety ontractors do not need to report radiopharmaceuticals Part shall report pricing information for drugs, biologicals, and radiopharmaceuticals that are billed using ontractors shall download the most current version available of the template from the eb site at ontractors shall complete the template on a monthly basis The template shall be in xcel format ontractors shall send the completed template to sec0aspdata@cms.hhs.gov on the first business day of the month f the contractor has not priced any drugs since the last submitted report, in lieu of using the template, the contractor shall send an to ec0aspdata@cms.hhs.gov stating that the contractor has no drug pricing to report.. PROR UTON TBL 95.7 LN rticle: provider education article related to this instruction will be

8 available at Network-LN/LNattersrticles/ shortly after the R is released. You will receive notification of the article release via the established "LN atters" listserv. ontractors shall post this article, or a direct link to this article, on their eb sites and include information about it in a listserv message within 5 business days after receipt of the notification from announcing the availability of the article. n addition, the provider education article shall be included in the contractor's next regularly scheduled bulletin. ontractors are free to supplement LN atters articles with localized information that would benefit their provider community in billing and administering the edicare program correctly.. UPPORTNG NORTON ection : Recommendations and supporting information associated with listed requirements: N/ "hould" denotes a recommendation. -Ref Requirement Number Recommendations or other supporting information: ection B: ll other recommendations and supporting information: N/. ONTT Pre-mplementation ontact(s): Glenn cguirk, or Glenn.cGuirk@cms.hhs.gov Post-mplementation ontact(s): ontact your ontracting Officer's Representative (OR).. UNNG ection : or edicare dministrative ontractors (s): The edicare dministrative ontractor is hereby advised that this constitutes technical direction as defined in your contract. does not construe this as a change to the tatement of ork. The contractor is not obligated to incur costs in excess of the amounts allotted in your contract unless and until specifically authorized by the ontracting Officer. f the contractor considers anything provided, as described above, to be outside the current scope of work, the contractor shall withhold performance on the part(s) in question and immediately notify the ontracting Officer, in writing or by , and request formal directions regarding continued performance requirements. TTNT: 0