decisionhealth Newsletters, Answer Books - 2006 Issue 3 (March)
Program_Memos / 2003 / B-03-012
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Article Overview
This article explains a CMS program memorandum issued to update drug-claim processing at DMERCs under HIPAA-related standards. It covers the transition from HCPCS-based drug handling to NDC-based claim identification, associated business requirements, crosswalk maintenance, electronic and paper claim considerations, and implementation timing. It is relevant to Medicare billing staff, pharmacy providers, DME Medicare contractors, and systems teams responsible for claims processing and remittance workflows.
Why This Topic Matters
It documents a Medicare claims-processing change that affects how drug claims are identified, edited, crosswalked, and reported. Organizations involved in pharmacy billing, DME contractor operations, and claims system configuration need this guidance to align processes with CMS requirements and implementation dates.
Article Sections
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Program Memorandum
Introductory memorandum information from CMS and DHHS, including transmittal and change-request context.
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I - General Information
Background on the policy update, the HIPAA-related framework, and the general purpose of the memorandum. This section also introduces the subject matter and the entities affected.
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Description of NDC
Overview of the National Drug Code system, its origin, and its relationship to drug listing and FDA-maintained drug information resources.
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DMERC Claims Processing
Claims-processing guidance for retail pharmacy submissions, including format considerations, claim handling, and operational impacts for contractors and systems.
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B - Policy
Policy statements describing the expected claim-identification and adjudication approach for affected drug claims.
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II - Business Requirements
Detailed operational requirements for DMERCs, system maintainers, and related entities, including claim acceptance, crosswalks, reporting, and processing support.
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III - Supporting Information and Possible Design Considerations
Supplemental implementation notes, design considerations, interface status, testing notes, and related administrative information.
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A - Other Instructions
Distribution and provider-education instructions tied to the implementation of the memorandum.
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B - Design Considerations
Statement regarding system design considerations.
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C - Interfaces
Statement regarding interface considerations.
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D - Contractor Financial Reporting /Workload Impact
Statement regarding financial reporting and workload impact.
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E - Dependencies
Statement regarding dependencies.
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F - Testing Considerations
Statement regarding testing considerations.
What You Will Learn
- The scope of the CMS memorandum and the Medicare contractor workflow it affects.
- The general categories of claims-processing changes tied to NDC-based drug billing.
- Which organizations and system components are involved in implementing the update.
- The implementation timeline and related administrative considerations.
- The types of operational issues addressed for electronic and paper submissions.
Who Should Read This
- Medicare claims processors
- DME MAC / DMERC operational staff
- Pharmacy billing staff
- Revenue cycle and reimbursement teams
- Healthcare IT and claims system analysts
- Compliance and regulatory staff
Codes Discussed
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