Medicare_Claims_Processing_Manual / 4309

Why This Topic Matters

The article documents CMS-directed changes that affect how CAP-related claims are handled, how information is exchanged among carriers and vendors, and how related beneficiary notices are presented. It helps readers determine whether their Medicare claims, system edits, or operational procedures are affected by the CAP update.

Article Sections

1. Summary of Changes

   Overview of the transmittal purpose, effective and implementation dates, and the manual sections affected by the update.

2. Attachment - Business Requirements

   Background, policy context, and business requirement references associated with the CAP update.

3. Carrier Specific Requirements for Certain Specialties/Services

   General claim-processing requirements for selected specialties and service types, including the CAP-related reference added to the section.

4. Chapter 17 - Drugs and Biologicals

   Table of contents and substantive manual updates for drugs and biologicals under the CAP framework.

5. Discarded Drugs and Biologicals

   General policy discussion for discarded drug amounts and its relationship to CAP-related billing processes.

6. The Competitive Acquisition Program (CAP) for Drugs and Biologicals Not Paid on a Cost or Prospective Payment Basis

   Program overview, participation framework, vendor arrangements, and high-level CAP operational structure.

7. Physician Election and Information Transfer Between Carriers and the Designated Carrier for CAP Claims

   Procedures for collecting and transmitting physician election and practice information between carriers and the designated carrier.

8. Claims Processing Instructions for CAP Claims for the Local Carriers

   Local carrier handling of CAP claims, including modifier-related edits, claim submission workflow, and related review processes.

9. Application of Local Medical Review Policies

   Use of coverage policies and regular edits when processing CAP-related claim lines.

10. Claims Processing Instructions for the Designated Carrier

    Designated carrier responsibilities for vendor enrollment, internal files, claim acceptance, messages, and CAP fee schedule support.

11. Matching the Physician Claim to the Vendor Claim

    High-level coordination of matching processes, claim status handling, recovery actions, and follow-up reporting.

12. Coordination of Benefits

    Coordination of benefits handling for CAP drug claims and crossover processing.

13. National Claims History

    Storage of prescription number information in national claims history systems.

14. Adding New Drugs to CAP

    Quarterly expansion processes for adding new vendor-specific HCPCS codes and related table updates.

15. Updating Fee Schedule for New Drugs in CAP

    Fee schedule maintenance for newly added CAP drugs and pricing updates.

16. Non-Participating Physicians Who Elect the CAP

    Participation-related billing considerations for physicians who elect CAP while remaining nonparticipating for other purposes.

17. General Information Section

    MSN language updates and beneficiary-facing general information entries, including CAP-related notice text.

18. Duplicates

    Duplicate claim notice language and CAP-related duplicate message updates.

19. Duplicados

    Spanish-language duplicate notice language and related CAP message updates.

20. Seccion De Informacion General

    Spanish-language general information entries, including CAP-related notice language.