Department of Health & Human Services (DHHS) Centers for Medicare & Medicaid Services (CMS) Transmittal 129 Date: November 25, 2015

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1 anual ystem Pub 00-9 emonstrations epartment of ealth & uman ervices () enters for edicare & edicaid ervices () Transmittal 29 ate: November 25, 205 hange Request 934 Transmittal 27, dated November 5, 205, is being rescinded and replaced by Transmittal 29, dated November 25, 205, to correct the P number and add P admin and pricing information located in the Business Requirement background section, BR 934.., BR and BR ll other information remains the same. UBJT: Oncology are odel (O) onthly nhanced Oncology ervices (O) Payment mplementation. URY O NG: This change request (R) is for the purpose of establishing the necessary systems' changes to implement the onthly nhanced Oncology ervices (O) Payments for the Oncology are odel. T T: pril, 206 *Unless otherwise specified, the effective date is the date of service. PLNTTON T: pril 4, 206 isclaimer for manual changes only: The revision date and transmittal number apply only to red italicized material. ny other material was previously published and remains unchanged. owever, if this revision contains a table of contents, you will receive the new/revised information only, and not the entire table of contents.. NG N NUL NTRUTON: (N/ if manual is not updated) R=R, N=N, =LT-Only One Per Row. R/N/ PTR / TON / UBTON / TTL N/. UNNG: or edicare dministrative ontractors (s): The edicare dministrative ontractor is hereby advised that this constitutes technical direction as defined in your contract. does not construe this as a change to the tatement of ork. The contractor is not obligated to incur costs in excess of the amounts allotted in your contract unless and until specifically authorized by the ontracting Officer. f the contractor considers anything provided, as described above, to be outside the current scope of work, the contractor shall withhold performance on the part(s) in question and immediately notify the ontracting Officer, in writing or by , and request formal directions regarding continued performance requirements.. TTNT: emonstrations

2 ttachment - emonstrations Pub Transmittal: 29 ate: November 25, 205 hange Request: 934 Transmittal 27, dated November 5, 205, is being rescinded and replaced by Transmittal 29, dated November 25, 205, to correct the P number and add P admin and pricing information located in the Business Requirement background section, BR 934.., BR and BR ll other information remains the same. UBJT: Oncology are odel (O) onthly nhanced Oncology ervices (O) Payment mplementation T T: pril, 206 *Unless otherwise specified, the effective date is the date of service. PLNTTON T: pril 4, 206. GNRL NORTON. Background: The purpose of this hange Request (R) is for the enters for edicare and edicaid ervices () to create system specifications that will successfully implement the monthly enhanced oncology services (O) payment for the Oncology are odel (O). O is a 5-year model intended to utilize appropriately aligned financial incentives to improve care coordination, appropriateness of care, and access to care for beneficiaries undergoing chemotherapy. O encourages participating practices to improve care and lower costs through a model that incorporates a O payment and episode-based payments. The nnovation enter expects that these improvements will result in better care, smarter spending, and healthier people. Practitioners in O are expected to rely on the most current medical evidence and shared decision-making with beneficiaries to inform their recommendation about whether a beneficiary should receive chemotherapy treatment. O provides an incentive to participating physician practices to comprehensively and appropriately address the complex care needs of the beneficiary population receiving chemotherapy treatment, and heighten the focus on furnishing services that specifically improve the patient experience and/or health outcomes. Practices that participate in O may receive O payments of $60 per beneficiary for care management and related practice transformation. B. Policy: O is an episode-based payment model targeting chemotherapy treatment and the spectrum of care provided to beneficiaries receiving chemotherapy. Participants will be physician practices that furnish chemotherapy treatments. O incorporates a two-part payment approach to provide financial support for participants to transform their practices, including a monthly O care management payment for participating edicare ee-for-ervice () beneficiaries and a retrospective performance-based payment. Both payments will be in addition to the services the physician provides and bills to edicare. This R focuses only on the O (G9678). The performance-based payment and its processing will be addressed in a separate R. The O O payment is a fixed amount of $60. t will not change over the course of the model or differ based on site of service. Participating practitioners and group practices will bill the O G code (G9678) for each O beneficiary. n cases where the O participant is a hospital or provider-based clinic, G9678 full payments will only be made to the professional component. There will be no institutional component. O providers will receive guidance on O billing rules, and the O shall reject any O claims billed to the institutional component

3 Prior to the start of the model in pril 206, and quarterly thereafter, will contractors to notify them that the updated list of O practices and practitioners is available in the mainframe. Only these practitioners will be eligible to bill G9678. contractors will not receive a list of participating beneficiaries, as the participating practitioners are eligible to bill the code for any beneficiary they believe is eligible for the model and attributed to their practice. ligible practitioners may bill the O G code once per calendar month per beneficiary. Participating practitioners will be ineligible to bill a range of other care management services (see ppendix ) and the O G code for the same beneficiary during the same month. Non-O practitioners could continue to bill any of these care management services for an O beneficiary, including during months when O practices are billing the O. dditionally, O practitioners providing care management services to an O beneficiary, but to whom the beneficiary is not attributed in the model, may also bill for any of these care management services, including the months when another O practice is billing the O. oinsurance and deductible payments by beneficiaries will not apply to G9678. G9678 will be subject to edicare penalties and payment adjustments (e.g. B, R ncentive Program, PQR reporting, etc.). G9678 will not be subject to GP or budget neutrality adjustments. will review the paid claims for G9678 and monitor for overpayment. On a semi-annual basis, the nnovation enter will submit to the s a list of G9678 and other non-o services provided in ppendix payments that need to be recouped from participating practices. These overpayments must be reprocessed and recouped, this process will be handled in a separate change request. NOT: new P code, G9678 Oncology are odel (O) onthly nhanced Oncology ervices (O) payment for enhanced care management services for O beneficiaries. O covers care management services for edicare beneficiaries in a 6-month O pisode of are triggered by the administration of chemotherapy. nhanced care management services include services driven by the O practice requirements, including: 24/7 clinician access, use of an ON-certified lectronic ealth Record, utilization of data for quality improvement, patient navigation, documentation of care plans, and use of clinical guidelines. (G9678 may only be billed for O beneficiaries by O practitioners) hort escriptor: Oncology are odel service has been created for this demonstration. t will be effective pril, 206. ode G9678 will be in the pril 206 edicare Physician ee chedule atabase (PB). G9678 will be allowed at a flat $60 and will not be subject to co-insurance and deducible.. BUN RQURNT TBL "hall" denotes a mandatory requirement, and "should" denotes an optional requirement. Number Requirement Responsibility /B hared- ystem aintainers 934. ffective for claims with dates of service on and after pril, 206 through arch 3, 202 contractors shall accept G9678 O ervice. B

4 /B hared- ystem aintainers B ffective pril, 206 contractors shall use TO for G ontractors shall allow $60 for G The ulti-arrier ystem esktop Tool (T) shall display P G9678, Oncology are odel ervice, on a separate screen and in a format equivalent to the R screen The O shall reject all detail lines with the O service shall split any detail lines containing the O service to a separate claim shall only process claim lines with the O service where the billing TN and rendering NP combination matches a combination provided on the enrolled provider file and where the date of service is on or after the ffective ate of Participation and on or before the nd ate of Participation (if present). O ontractors shall use the following messages for detail lines denied in BR R B7 - This provider was not certified/eligible to be paid for this procedure/service on this date of service. Group ode: O (ontractual Obligation) N This claim is being processed under a demonstration project. panish language translation: sta reclamación está siendo procesada bajo un projecto especial ontractors shall return as unprocessable all detail lines containing the O service with units of service greater than one () ontractors shall use the following messages for detail lines denied in BR R 9 - Benefit maximum for this time period or occurrence has been reached.

5 /B hared- ystem aintainers RR N362 - The number of ays or Units of ervice exceeds our acceptable maximum. B Group ode: O (ontractual Obligation) ontractors shall return as unprocessable any detail line containing the O service in which the from date does not equal the through date ontractors shall use the following messages for detail lines denied in BR R 52 - Payer deems the information submitted does not support this length of service. RR N640 - xceeds number/frequency approved/allowed within time period. Group ode: O (ontractual Obligation) shall confirm that the beneficiary at the time of the O service was enrolled in both edicare Parts and B and is not eligible through R ontractors shall deny detail lines that do not meet the eligibility requirements in BR.6. ontractors shall use the following messages for detail lines denied in BR R 77 - Patient has not met the required eligibility requirements. Group ode: O (ontractual Obligation) N This claim is being processed under a demonstration project. panish language translation: sta reclamación está siendo procesada bajo un projecto especial shall reject any detail line containing the O service when the date of service is in the same calendar month as another claim for the O service for that beneficiary.

6 /B hared- ystem aintainers ontractors shall use the following messages for detail lines denied in BR B R 9 - Benefit maximum for this time period or occurrence has been reached. Group ode: O (ontractual Obligation) N Payment is included in another service you have received. panish language translation: l pago fue incluido en otro servicio que usted recibió f a claim is received with a two detail lines for the O service with the dates of service for both details lines being in the same calendar month, shall deny the latter (based on date of service) of the two claims ontractors shall use the following messages for detail lines denied in BR R 9 - Benefit maximum for this time period or occurrence has been reached. Group ode: O (ontractual Obligation) N Payment is included in another service you have received. panish language translation: l pago fue incluido en otro servicio que usted recibió shall make available for download from the mainframe the Participant ile, which contains the list of participating providers who are allowed to bill the O service. The Participant ile will contain the following fields: Payment odel lphanumeric, 3 positions odel will equal O

7 /B hared- ystem aintainers Tax Number (TN) Numeric, 9 positions. B NP lphanumeric, 0 positions. ffective ate of Participation Numeric, 8 positions, in YY format. nd ate of Participation Numeric, 8 positions, in YY format. tatus lphanumeric, position, values are: Record deleted from the current file shall inform contractors and of the availability of the test Participant ile via on or around October 30, Upon receipt of notification from, and shall download and test the test Participant ile shall send error/response file via T acknowledging receipt of the test Participant ile. Note: The notification error/response file shall report indicate any outstanding issues related to the file transfer (if applicable). x: nvalid date, invalid TN, etc shall inform contractors of the availability of the first production Participant ile via on or around January 29, Upon receipt of notification from, and shall download and install the production Participant ile for the pril 206 release shall send error/response file via T acknowledging receipt of the first production Participant ile. Note: The notification error/response file shall report indicate any outstanding issues related to the file transfer (if applicable).

8 /B hared- ystem aintainers x: nvalid date, invalid TN, etc fter implementation shall make updates to the O participant list through a quarterly full replacement single national Participant ile. shall make available for download on the ainframe first of these update Participant iles on or around ay, 206. shall make subsequent updates on a quarterly basis. B shall inform the contractors and of the availability of the updated Participant ile via Upon receipt of notification from, and shall download and install the updated Participant ile for the next regular production release shall send error/response file via T acknowledging receipt of the Participant ile. Note: The notification error/response file shall report indicate any outstanding issues related to the file transfer (if applicable). x: nvalid date, invalid TN, etc shall reject any claim for the services found in ppendix for a beneficiary with a O service payment in the same calendar month, under the following conditions:. f a Part B professional claim is received for any of the listed services and the beneficiary already received a O service by the same billing and rendering provider in that calendar month 2. f a Part B professional claim is received for a beneficiary for any of the listed services with and the beneficiary already received a O service in the same calendar month, by the same billing provider as found in claims history, but a different rendering provider, who is also on the Participant ile

9 /B hared- ystem aintainers ontractors shall deny detail lines that receive an error from BR B or denied services contractors shall use the following messages: R 32 Prearranged demonstration project adjustment Group ode: O (contractual obligation) N Payment is included in another service you have received. panish language translation: l pago fue incluido en otro servicio que usted recibió shall deny any claim for the services found in ppendix which meets the following condition f both the O service and one of the listed services are billed on the same claim in different detail lines, and with dates of service the same calendar month, then shall allow only the O service, other service shall be denied or denied services contractors shall use the following messages: R 32 Prearranged demonstration project adjustment Group ode: O (contractual obligation) N Payment is included in another service you have received. panish language translation: l pago fue incluido en otro servicio que usted recibió The beneficiary will not be assessed co-insurance or deductible for the O service listed in BR ontractors shall apply all alue Based odifier (B), Physician Quality Reporting ystem (PQR) and lectronic ealth Records (R) adjustments to

10 /B hared- ystem aintainers the O service payment. B. PROR UTON TBL Number Requirement Responsibility None /B B. UPPORTNG NORTON ection : Recommendations and supporting information associated with listed requirements: N/ "hould" denotes a recommendation. -Ref Requirement Number Recommendations or other supporting information: ection B: ll other recommendations and supporting information: N/. ONTT Pre-mplementation ontact(s): an Kramer, or ian.kramer@cms.hhs.gov, Laura ortimer, or laura.mortimer@cms.hhs.gov (or policy inquiries) Post-mplementation ontact(s): ontact your ontracting Officer's Representative (OR).. UNNG ection : or edicare dministrative ontractors (s): The edicare dministrative ontractor is hereby advised that this constitutes technical direction as defined in your contract. does not construe this as a change to the tatement of ork. The contractor is not obligated to incur costs in excess of the amounts allotted in your contract unless and until specifically authorized by the ontracting Officer. f the contractor considers anything provided, as described above, to be outside the current scope of work, the contractor shall withhold performance on the part(s) in question and immediately notify the ontracting Officer, in writing or by , and request formal directions regarding continued performance requirements. TTNT:

11 ppendix : List of services which conflict with the PBP service: hron care mgmt srvc 20 min Trans care mgmt 4 day disch Trans care mgmt 7 day disch ome health care supervision ome health care supervision ospice care supervision ospice care supervision 9095 srd serv 4 visits p mo <2yr srd serv 2-3 vsts p mo <2yr srd serv visit p mo <2yrs srd serv 4 vsts p mo srd srv 2-3 vsts p mo srd srv visit p mo srd srv 4 vsts p mo srd srv 2-3 vsts p mo srd serv vst p mo srd srv 4 visits p mo srd srv 2-3 vsts p mo srd serv visit p mo srd home pt serv p mo <2yrs srd home pt serv p mo srd home pt serv p mo srd home pt serv p mo 20+

12 90967 srd home pt serv p day < srd home pt srv p day srd home pt srv p day srd home pt serv p day 20+

Department of Health & Human Services (DHHS) Centers for Medicare & Medicaid Services (CMS) Transmittal 1356 Date: March 6, 2014

Department of Health & Human Services (DHHS) Centers for Medicare & Medicaid Services (CMS) Transmittal 1356 Date: March 6, 2014 anual ystem Pub 100-20 One-Time Notification epartment of ealth & uman ervices () enters for edicare & edicaid ervices () Transmittal 1356 ate: arch 6, 2014 hange Request 8456 Transmittal 1336, dated ebruary