Medicare_Claims_Processing_Manual / transmittal_248

Why This Topic Matters

The transmittal affects how Medicare contractors load and use drug pricing files, how payment limits are established, and how certain drug-related claims are processed. Understanding the scope helps organizations track manual changes, operational deadlines, and the general pricing framework without relying on the full premium text.

Article Sections

1. Summary of Changes

   Overview of the manual updates and the implementation timeline for the revised drug pricing instructions.

2. Attachment - Business Requirements

   Operational requirements for contractors, including file handling, posting, pricing updates, and related administrative responsibilities.

3. Payment Rules for Drugs and Biologicals

   General Medicare payment framework for drugs and biologicals across inpatient, outpatient, and other covered settings.

4. MMA Drug Pricing -- Average Sales Price

   Introduction to ASP-based pricing limits and the associated Medicare pricing methodology.

5. Single Drug Pricer (SDP)

   Description of the pricing files used for drug claims and the general handling of those files by contractors.

6. Calculation of the Payment Allowance Limit for DMERC Drugs

   High-level discussion of payment allowance limit calculation for drugs processed by DMERCs.

7. Calculation of the AWP

   General methodology for establishing average wholesale price figures and related pricing calculations.

8. Detailed Procedures for Determining AWPs and the Drug Payment Allowance Limits

   Detailed manual guidance on sources, review steps, restrictions, and the broader pricing workflow.

9. Background

   Context for the drug payment allowance limit methodology and references to governing authority.

10. Review of Sources for Medicare Covered Drugs and Biologicals

    Broad discussion of information sources and review steps used in drug pricing research.

11. Use of Generics

    General guidance on identifying generic versus brand products for pricing purposes.

12. Find the Strength and Dosage

    Overview of how strength and dosage information is matched to pricing source data.

13. Restrictions

    Summary of exclusions and limitations affecting drug pricing source selection.

14. Inherent Reasonableness for Drugs and Biologicals

    Discussion of the inherent reasonableness concept as it applies to drug and biological payment amounts.

15. Injection Services

    General billing and payment treatment for certain injection-related services.

16. Injections Furnished to ESRD Beneficiaries

    Broad instructions for injections related to ESRD beneficiaries and monthly capitation payment considerations.