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Medical Oncology Association of Southern California
P.O. Box 161
Upland, CA 91785
Phone: (909) 985-9061
Fax: (909) 985-8581
email: moasc@moasc.org


MOASC Sponsors

MOASC would like to recognize and thank the following sponsors for their continued support of MOASC:

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Click on the links below to locate contact information for members of Congress:
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News & Updates
Posted June 19, 2005

July 2005 3rd Quarter ASP Pricing File Posted
The July 2005 quarterly update for the Average Sales Price (ASP) Medicare Part B Drugs pricing file has been posted today on the Centers for Medicare and Medicaid Services (CMS) website. Download the file here: http://www.cms.hhs.gov/providers/drugs/asp.asp


Beneficiaries Should Not Call Provider Line
NHIC would like to remind providers not to give out the provider phone number to their patients. Beneficiaries are to call 1-800-MEDICARE for questions concerning Medicare.



Billing For Unlisted Drugs and Procedures
Recent telephone calls and written inquiries reveal that many billers have questions concerning the reporting of unlisted procedures or unlisted drugs. The following information will guide you in the process. Reference: CPT and HCPCS Coding Books



Medicare Newsletter Index
The Newsletter Index for the Medicare B Resource has been updated to include articles from the June 2005 edition.



Change in the First Level of Appeal: Redetermination 

A redetermination is an examination of a claim by Carrier personnel who are independent of the personnel who made the initial determination. The appellant (the individual filing the appeal) has 120 days from the date of receipt of the initial claim determination to file an appeal. Read how to request a redetermination here.



Invalid/Incomplete Medicare Provider Identification Numbers (Medicare Provider  PINs)
NHIC identified that some providers are submitting claims with incomplete or invalid PIN information. We ask that when submitting claims to Part B to please follow the guidelines relating to Item 24K and Item 33 of the CMS-1500 claim form.



Seminars - Ask the Contractor Teleconferences (ACT)
Ask the Contractor Teleconferences are similar to the Open Door Forums offered by the Centers for Medicare & Medicaid Services (CMS). They serve to identify problems, respond to questions in a timely manner, provide methods of sharing information, and are an excellent tool to listen to providers - our customers. This is your opportunity to speak directly to your Medicare contractor on various topics.



ASP Pricing File Updates
New April 2005 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing File and Revisions to January 2005 ASP Medicare Part B Drug Pricing File has been posted.



June 2005 Medicare B Resource
The June 2005 Medicare B Resource has been posted. (.pdf format)



CMS Describes Payment Methodology for the Medicare Modernization Act of 2003 (MMA)

The Medicare Modernization Act of 2003 (MMA), Section 303(c), revises the methodology of paying for Part B covered drugs and biologicals that are not paid on a cost or prospective payment basis. Effective January 1, 2005, these drugs are paid based on the new Average Sales Price (ASP) drug payment methodology.

The ASP file, used in the ASP methodology, is based on data CMS receives quarterly from manufacturers. Each quarter, the Centers for Medicare & Medicaid Services (CMS) will update your carrier and Fiscal Intermediary (FI) payment allowance limits with the ASP drug pricing files based on these manufacturers’ data.

Beginning January 1, 2005, the payment allowance limits for Medicare Part B drugs and biologicals that are not paid on a cost or prospective payment basis are 106 percent of the ASP, and CMS will update the payment allowance limits quarterly. However, there are exceptions to this general rule as summarized below:

• For blood and blood products (with certain exceptions like blood clotting factors), payment allowance limits are determined in the same manner they were determined on October 1, 2003. Specifically, the payment allowance limits for blood and blood products are 95 percent of the Average Wholesale Price (AWP) as reflected in the published compendia. The payment
allowance limits will be updated on a quarterly basis.

• For infusion drugs furnished through a covered item of Durable Medical Equipment (DME) on or after January 1, 2005, payment allowance limits will continue to be 95 percent of the AWP reflected in the published compendia as of October 1, 2003 regardless of whether or not the DME is implanted. The payment allowance limits will not be updated in 2005.

• For influenza, pneumococcal, and hepatitis B vaccines payment allowance limits are 95 percent of the AWP as reflected in the published compendia. The payment allowance limits will be updated on a quarterly basis.

• For drugs, other than new drugs, not included in the ASP Medicare Part B Drug Pricing File or Not Otherwise Classified (NOC) Pricing File payment allowance limits are based on the published Wholesale Acquisition Cost (WAC) or invoice pricing. In determining the payment limit based on WAC, carriers/FIs will follow the methodology specified in the Medicare Claims Processing Manual for calculating the AWP, but substitute WAC for AWP. Please see Pub. 100-04, Chapter 17 (Drugs and Biologicals) at the following CMS web site: http://www.cms.hhs.gov/manuals/104_claims/clm104c17.pdf. The payment limit is 100 percent of the WAC for the lesser of the lowest brand or median generic. Your carrier or FI may, at their discretion, contact CMS to obtain payment limits for drugs not included in the quarterly ASP or NOC files. If available, CMS will provide the payment limits either directly to the requesting carrier/FI or via posting an MS Excel file on the CMS web site. If the payment limit is available from CMS, carriers/FIs will substitute CMS-provided payment limits for pricing
based on WAC or invoice pricing.

• For new drugs and biologicals not included in the ASP Medicare Part B Drug Pricing File or NOC Pricing File, payment allowance limits are based on 106 percent of the WAC. This policy applies only to new drugs that were first sold on or after December 1, 2004. The April 2005 and new January 2005 ASP drug pricing files will contain three decimal places in the currency fields. In addition, the new January file contains revised payment limits for some drugs. The codes with a revised payment limit are identified in the column titled “Notes.” The absence or presence of a HCPCS code and its associated payment limit in the pricing files do not indicate Medicare coverage of the drug. Similarly, the inclusion of a payment limit within a specific column does not indicate Medicare coverage of the drug in that specific category. The carrier/FI processing your claim will make these determinations. In addition, your carrier or FI is required to accomplish the following:

• Use the April 2005 ASP and NOC drug pricing files to pay for Medicare Part B drugs effective April 1, 2005. This file shall be used for dates of service from April 1, 2005 through June 30, 2005;

• Determine for any drug or biological not listed in the ASP or NOC drug pricing files, the payment allowance limits in accordance with the policies described in this transmittal, CR3539, dated October 29, 2004 (see http://www.cms.hhs.gov/manuals/pm_trans/R348CP.pdf), and CR3232, dated December 16, 2004 (see http://www.cms.hhs.gov/manuals/pm_trans/R397CP.pdf), and FIs should seek payment allowances from their local carrier;

• Use the new January 2005 ASP drug pricing file for (1) those claims where the carriers/FIs are asked to retroactively adjust claims processed with the original January 2005 file and (2) those claims with dates of service on or after January 1, 2005 and before April 1, 2005 that are processed after April 4, 2005. Your carrier or FI shall not search and adjust claims that have
already been processed unless brought to their attention;

• Overlay the old January 2005 file with the new January 2005 file; and

• For any drug or biological for which they (your carrier or FI) calculates a payment allowance limit, forward to CMS the following:

• The drug name,
• Dosage,
• Payment allowance limit, and
• National Drug Code (if available).

Note: The ASP and NOC drug pricing files will contain the 106 percent ASP, 106 percent WAC or WAC based payment allowance limits; therefore, no additional payment calculation is required by your carrier or FI. The payment limits for the blood clotting factor codes includes the $0.14 per I.U. furnishing fee.

Additional Information
The new January 2005 and April 2005 ASP and NOC Pricing Files are available from the following CMS Website on or after March 17, 2005: http://www.cms.hhs.gov/providers/drugs/asp.asp

You can find more information about the April 2005 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing File, Effective April 1, 2005, and New January 2005 Quarterly ASP File at: http://www.cms.hhs.gov/manuals/transmittals/comm_date_dsc.asp

From that web page, look for CR 3667 in the CR NUM column on the right, and click on the file for that CR. If you have any questions, please contact your carrier/intermediary at their toll-free number, which may be found at: http://www.cms.hhs.gov/medlearn/tollnums.asp


MOASC 2006 Drug Grid

MOASC Calendar

The MOASC calendar is now available online!

Please log onto the MOASC weboffice site so you can see the calendar all the way through 2008. The URL is: http://moasccalendar.
webexone.com

Contact the MOASC office for log-in information.

MOASC Marketplace
Position: Oncologist seeking California Read More>>


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Drug Updates & Hotlines

Partnership For Prescriptions Assistance lists all major pharmaceutical companies and their contact information for patient assistance programs.

Drug Reimbursement & Support Programs Hotlines

MOASC Member Directory
The 2006-2007 MOASC Membership Directory is available for download.