MLN Matters® Number: MM6708
Related Change Request (CR) #: 6708
Related CR Release Date: November 13, 2009
Effective Date: January 1, 2010
Related CR Transmittal #: R1854CP
Implementation Date: January 4, 2010
Provider Types Affected
All physicians, providers and suppliers who submit claims to Medicare contractors (Medicare Administrative Contractors (MACs), Fiscal Intermediaries (FIs), carriers, Durable Medical Equipment Medicare Administrative Contractors (DME MACs) or Regional Home Health Intermediaries (RHHIs)) for services provided to Medicare beneficiaries.
Provider Action Needed
This article is based on Change Request (CR) 6708, which instructs Medicare contractors to download and implement the January 2010 ASP drug pricing file for Medicare Part B drugs; and if released by the Centers for Medicare & Medicaid Services (CMS), also the revised October 2009, July 2009, April 2009, and January 2009 files. Medicare will use the January 2010 ASP and not otherwise classified (NOC) drug pricing files to determine the payment limit for claims for separately payable Medicare Part B drugs processed or reprocessed on or after January 4, 2010, with dates of service January 1, 2010, through March 31, 2010. See the Background and Additional Information Sections of this article for further details regarding these changes.
Background
Section 303(c) of the Medicare Modernization Act of 2003 revised the payment methodology for Part B covered drugs and biologicals that are not paid on a cost or prospective payment basis. Beginning January 1, 2005, the vast majority of drugs and biologicals not paid on a cost or prospective payment basis are paid based on the ASP methodology, and pricing for compounded drugs has been performed by the local contractor.
The ASP methodology is based on quarterly data submitted to CMS by manufacturers. Note that payment allowance limits under the Outpatient Prospective Payment System (OPPS) are incorporated into the Outpatient Code Editor (OCE) under a separate CR.
The following table shows how the quarterly payment files will be applied (for those files that are released):
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Files
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Effective Dates of Service
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January 2010 ASP and NOC files
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January 1, 2010 through March 31, 2010
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October 2009 ASP and NOC files
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October 1, 2009 through December 31, 2009 |
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July 2009 ASP and NOC files
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July 1, 2009 through September 30, 2009
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April 2009 ASP and NOC files
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April 1, 2009 through June 30, 2009
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January 2009 ASP and NOC files
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January 1, 2009 through March 31, 2009
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Additional Information
If you have questions, please contact the Palmetto GBA Provider Contact Center at their toll-free number, (866) 332-7025 (Ohio and West Virginia) or (888) 828-2092 (South Carolina Part B).
Disclaimer
This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents. CPT only copyright 2009 American Medical Association.