Department of Health & Human Services (DHHS) Centers for Medicare & Medicaid Services (CMS) Transmittal 3290 Date: July 10, 2015

Transcription

1 anual ystem Pub edicare laims Processing epartment of ealth & uman ervices () enters for edicare & edicaid ervices () Transmittal 3290 ate: July 10, 2015 hange Request 9248 UBJT: October 2015 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: October 1, 2015 *Unless otherwise specified, the effective date is the date of service. PLNTTON T: October 5, 2015 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: 3290 ate: July 10, 2015 hange Request: 9248 UBJT: October 2015 Quarterly verage ales Price (P) edicare Part B rug Pricing iles and Revisions to Prior Quarterly Pricing iles T T: October 1, 2015 *Unless otherwise specified, the effective date is the date of service. PLNTTON T: October 5, 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: This Recurring Update addresses the following pricing files: ile: October 2015 P and P NO -- ffective ates of ervice: October 1, 2015, through ecember 31, 2015 ile: July 2015 P and P NO -- ffective ates of ervice: July 1, 2015, through eptember 30, 2015 ile: pril 2015 P and P NO -- ffective ates of ervice: pril 1, 2015, through June 30, 2015 ile: January 2015 P and P NO -- ffective ates of ervice: January 1, 2015, through arch 31, 2015 ile: October 2014 P and P NO -- ffective ates of ervice: October 1, 2014, through ecember 31, BUN RQURNT TBL "hall" denotes a mandatory requirement, and "should" denotes an optional requirement. Number Requirement Responsibility /B hared- ystem aintainers The October 2015 and, if released, the revised July 2015, pril 2015, January 2015, and October 2014, P drug pricing files for edicare Part B drugs will be available via the ata enter (). B ontractors shall download the October 2015 P drug pricing file through the on or after eptember 16, 2015.

3 /B hared- ystem aintainers B inal ile: U00.@B12390.P.R2.Y15.OT ontractors shall retrieve the October 2015 P NO pricing file from the P webpage on or after eptember 16, ontractors shall use the October 2015 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 October 5, 2015 with dates of service October 1, 2015, through ecember 31, ontractors shall use the October 2015 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 October 5, 2015, with dates of service on or after October 1, f released by, contractors shall download the revised July 2015 P drug pricing file through the on or after eptember 16, inal ile: U00.@B12390.P.R2.Y15.JUL f released by, contractors shall overlay or manually update the previous July 2015 file with the new July 2015 P drug pricing file f released by, contractors shall use the revised July 2015 P drug pricing file to determine the edicare Part B drugs processed or reprocessed on or after October 5, 2015 with dates of service July 1, 2015, through eptember 30, f released by, contractors shall retrieve the revised July 2015 P NO pricing file from the P webpage on or after eptember 16, f released by, contractors shall use the revised July 2015 P NO pricing file to determine the

4 /B hared- ystem aintainers edicare Part B drugs processed or reprocessed on or after October 5, 2015 with dates of service July 1, 2015, through eptember 30, B f released by, contractors shall download the revised pril 2015 P drug pricing file through the on or after eptember 16, inal ile: U00.@B12390.P.R2.Y15.PR f released by, contractors shall overlay or manually update the previous pril 2015 file with the new pril 2015 P drug pricing file f released by, contractors shall use the revised pril 2015 P drug pricing file to determine the edicare Part B drugs processed or reprocessed on or after October 5, 2015 with dates of service pril 1, 2015, through June 30, f released by, contractors shall retrieve the revised pril 2015 P NO pricing file from the P webpage on or after eptember 16, f released by, contractors shall use the revised pril 2015 P NO pricing file to determine the edicare Part B drugs processed or reprocessed on or after October 5, 2015 with dates of service pril 1, 2015, through June 30, f released by, contractors shall download the revised January 2015 P drug pricing file through the on or after eptember 16, inal ile: U00.@B12390.P.R2.Y15.JN f released by, contractors shall overlay or manually update the previous January 2015 file with the new January 2015 P drug pricing file f released by, contractors shall use the revised January 2015 P drug pricing file to determine the

5 /B hared- ystem aintainers edicare Part B drugs processed or reprocessed on or after October 5, 2015 with dates of service January 1, 2015, through arch 31, B f released by, contractors shall retrieve the revised January 2015 P NO pricing file from the P webpage on or after eptember 16, f released by, contractors shall use the revised January 2015 P NO pricing file to determine the edicare Part B drugs processed or reprocessed on or after October 5, 2015 with dates of service January 1, 2015, through arch 31, f released by, contractors shall download the revised October 2014 P drug pricing file through the on or after eptember 16, inal ile: U00.@B12390.P.R2.Y14.OT f released by, contractors shall overlay or manually update the previous October 2014 file with the new October 2014 P drug pricing file f released by, contractors shall use the revised October 2014 P drug pricing file to determine the edicare Part B drugs processed or reprocessed on or after October 5, 2015 with dates of service October 1, 2014, through ecember 31, f released by, contractors shall retrieve the revised October 2014 P NO pricing file from the P webpage on or after eptember 16, f released by, contractors shall use the revised October 2014 P NO pricing file to determine the edicare Part B drugs processed or reprocessed on or after October 5, 2015 with dates of service October 1, 2014, through ecember 31, ontractors shall not search and adjust claims that have already been processed unless brought to their attention.

6 /B hared- ystem aintainers B Notification of successful receipt shall be sent via e- to price_file_receipt@cms.hhs.gov stating the name of the file received and the entity for which it was received (e.g., /B s/ /ontractor name and number) The P and NO drug pricing files will contain the applicable payment allowance limits (i.e., 106% P, 106%, 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 17, ection /B 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 report only once or compounded drugs, contractors shall report the name of each drug in the compounded product ontractors shall prepare and submit the reports so

7 /B hared- ystem aintainers that each report covers approximately 30 days of pricing activity. B 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 /B 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 sec303aspdata@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 ec303aspdata@cms.hhs.gov stating that the contractor has no drug pricing to report.. PROR UTON TBL Number Requirement Responsibility /B B

8 LN rticle: provider education article related to this instruction will be 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. /B B. 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