Department of Health & Human Services (DHHS) Centers for Medicare & Medicaid Services (CMS) Transmittal 2786 Date: September 13, 2013

Transcription

1 anual Pub edicare laims Processing epartment of ealth & uman ervices () enters for edicare & edicaid ervices () Transmittal 2786 ate: eptember 13, 2013 hange equest 8433 UBJT: nfluenza accine Payment llowances - nnual Update for eason. UY O NG This recurring update notification provides the payment allowances for the following seasonal influenza virus vaccines as updated on an annual basis effective ugust 1 of each year. The attached recurring update applies to Pub , chapter 17, section T T: ugust 1, 2013 PLNTTON T: No later than October 25, 2013 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 NTUTON: (N/ if manual is not updated) =, N=N, =LT-Only One Per ow. /N/ N/ PT / TON / UBTON / TTL N/. UNNG: or iscal ntermediaries (s), egional ome ealth ntermediaries (s) and/or arriers: No additional funding will be provided by ; ontractors activities are to be carried out with their operating budgets 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 statement of ork. The contractor is not obliged 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: ecurring Update Notification *Unless otherwise specified, the effective date is the date of service.

2 ecurring Update Notification Pub Transmittal: 2786 ate: eptember 13, 2013 hange equest: 8433 UBJT: nfluenza accine Payment llowances - nnual Update for eason T T: ugust 1, 2013 PLNTTON T: No later than October 25, GNL NOTON. Background: This recurring update notification provides the payment allowances for the following seasonal influenza virus vaccines: PT codes 90654, 90655, 90656, 90657, 90661, 90662, 90672, 90673, 90685, 90686, 90687, and 90688, and P codes Q2033, Q2035, Q2036, Q2037, and Q2038, when payment is based on 95 percent of the verage holesale Price (P). The edicare Part B payment allowances below apply for the indicated effective dates: PT Payment allowance is $ ffective dates: 8/1/2013-7/31/2014 PT Payment allowance is $ ffective dates: 8/1/2013-7/31/2014 PT Payment allowance is $ ffective dates: 8/1/2013-7/31/2014 PT Payment allowance is pending. ffective dates: 8/1/2013-7/31/2014 PT Payment allowance is $ ffective dates: 8/1/2013-7/31/2014 PT Payment allowance is $ ffective dates: 8/1/2013-7/31/2014 PT Payment allowance is pending. ffective dates: pending-7/31/2014 PT Payment allowance is pending. ffective dates: pending-7/31/2014 P Q2035 Payment allowance is $ ffective dates: 8/1/2013-7/31/2014 P Q2036 Payment allowance is $ ffective dates: 8/1/2013-7/31/2014 P Q2037 Payment allowance is $ ffective dates: 8/1/2013-7/31/2014 P Q2038 Payment allowance is $ ffective dates: 8/1/2013-7/31/2014 P Q2039 lu accine dult - Not wise lassified payment allowance is to be determined by the local claims processing contractor with effective dates of 8/1/2013-7/31/2014. Payment allowances for codes for which products have not yet been approved (including but not limited to PT codes and 90688) will be provided when the products have been approved and pricing information becomes available to. Payment for the following PT or P codes may be made if the local claims processing contractor determines its use is reasonable and necessary for the beneficiary, during the effective dates indicated below: PT Payment allowance is $ ffective dates: 8/1/2013-7/31/2014

3 PT Payment allowance is $ ffective dates: 8/1/2013-7/31/2014 PT Payment allowance is $ ffective dates: 8/1/2013-7/31/2014 P Q2033 Payment allowance is pending. ffective dates: 8/1/ /31/2013 PT Payment allowance is pending. ffective dates: 1/1/2014-7/31/2014 The payment allowances for pneumococcal vaccines are based on 95 percent of the P and are updated on a quarterly basis via the Quarterly verage ales Price (P) rug Pricing iles. B. Policy: The edicare Part B payment allowance limits for influenza and pneumococcal vaccines are 95 percent of the P as reflected in the published compendia except where the vaccine is furnished in a hospital outpatient department, ural ealth linic (), or ederally Qualified ealth enter (Q). here the vaccine, or Q, payment for the vaccine is based on reasonable cost. nnual Part B deductible and coinsurance amounts do not apply. ll physicians, non-physician practitioners and suppliers who administer the influenza virus vaccination and the pneumococcal vaccination must take assignment on the claim for the vaccine.. BUN QUNT TBL "hall" denotes a mandatory requirement, and "should" denotes an optional requirement ffective for dates of service on or after ugust 1, PT is $ , except where the vaccine aintainers ffective for dates of service on or after ugust 1, PT is $ , except where the vaccine ffective for dates of service on or after ugust 1, PT is $ 6.022, except where the vaccine is furnished in the hospital outpatient department, ffective for dates of service on or after ugust 1, PT is pending, except where the vaccine is furnished in the hospital outpatient department,

4 aintainers ffective for dates of service on or after ugust 1, PT is $ , except where the vaccine ffective for dates of service on or after ugust 1, PT is $ , except where the vaccine will post payment limits for influenza vaccines that are approved after the release date of this (including but not limited to PT code & 90688) on the easonal nfluenza accines Pricing webpage at ervice-part-b- rugs/crpartbrugvgalesprice/accinesprici ng.html as information becomes available. ontractors shall periodically monitor this webpage and obtain updated payment limits during the influenza season. ffective dates for these vaccines shall be the date of approval ffective for dates of service on or after ugust 1, P Q2035 is $ , except where the department, ffective for dates of service on or after ugust 1, P Q2036 is $ 8.579, except where the department, ffective for dates of service on or after ugust 1, P Q2037 is $ , except where the department,

5 ffective for dates of service on or after ugust 1, P Q2038 is $ , except where the department, aintainers ffective for dates of service on or after ugust 1, P Q2039 shall be determined by contractor discretion unless otherwise specified ontractors shall make payment for PT if its use is determined to be reasonable and ffective for dates of service on or after ugust 1, PT is $ , except where the vaccine ontractors shall make payment for P Q2033 if its use is determined to be reasonable and ffective for dates of service from ugust 1, 2013 to ecember 31, 2013, the edicare Part B payment allowance for P Q2033 is pending, except where the vaccine is furnished in the hospital outpatient department, ontractors shall make payment for PT after January 1, 2014, if its use is determined to be reasonable and ffective for dates of service on or after January 1, 2014, the edicare Part B payment allowance for PT is pending, except where the vaccine is furnished in the hospital outpatient department, ontractors shall make payment for PT if its use is determined to be reasonable and ffective for dates of service on or after ugust 1,

6 PT is $ , except where the vaccine aintainers ontractors shall make payment for PT if its use is determined to be reasonable and ffective for dates of service on or after ugust 1, PT is $ , except where the vaccine ontractors shall not search their files either to retract payment for claims already paid or to retroactively pay claims. owever, contractors shall adjust claims brought to their attention.. PO UTON TBL LN rticle: provider education article related to this instruction will be available at ducation/edicare-learning-network- LN/LNattersrticles/ shortly after the is released. You will receive notification of the article release via the established "LN atters" listserv. ontractors shall post this article, or a direct link to this article, on their eb sites and include information about it in a listserv message within one week of the availability of the provider education article. n addition, the provider education article shall be included in the contractor s next regularly scheduled bulletin. ontractors are free to supplement LN atters articles with localized information that would benefit their provider

7 community in billing and administering the edicare program correctly.. UPPOTNG NOTON ection : ecommendations and supporting information associated with listed requirements: "hould" denotes a recommendation. X-ef equirement Number ecommendations or other supporting information: None. ection B: ll other recommendations and supporting information: N/. ONTT Pre-mplementation ontact(s): Prabath alluwa-adu, or prabath.malluwawadu@cms.hhs.gov Post-mplementation ontact(s): ontact your ontracting Officer's epresentative (O) or ontractor anager, as applicable.. UNNG ection : or iscal ntermediaries (s), egional ome ealth ntermediaries (s), and/or arriers: No additional funding will be provided by ; ontractors activities are to be carried out with their operating budgets ection B: or edicare dministrative ontractors (s): The edicare dministrative ontractor is hereby advised that this constitutes technical direction as defined in your contract. do 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.