US · guidance
CMS Pub. 100-04, ch. 17, § 100.2.1
CAP Required Modifiers
The A/B MAC (B) shall identify physicians who have elected CAP and will no longer
pay the physician for drugs under the ASP system that were obtained through CAP. A/B
MACs (B) shall continue to pay physicians for the administration of CAP drugs. Unless
claims for the CAP drugs include the no-pay (J1), furnish as written (J3) modifier, or
MSP (M2) modifier the claim will be denied.
When physicians submit a claim for a drug they have provided under the CAP without
the J1, J3, or MSP modifiers, the contractor shall use the following remittance advice
messages and associated codes when rejecting/denying claims under this policy. This
CARC/RARC combination is compliant with CAQH CORE Business Scenario Three.
Group Code: CO
CARC: 96
RARC: N348
MSN: 7.7
A/B MACs (B) shall treat as unprocessable CAP claims with the following invalid
modifier combinations on CAP claims:
J1 + J3 - invalid
J2 without a J1 - invalid
J2 + J3 - invalid
A/B MACs (B) shall treat as unprocessable claims received with invalid modifier
combinations.
The contractor shall use the following remittance advice messages and associated codes
when rejecting/denying claims under this policy. This CARC/RARC combination is
compliant with CAQH CORE Business Scenario Two.
Group Code: CO
CARC: 16
RARC: N519
MSN: N/A
History
(Rev. 3721, Issued: 02-24-17, Effective: 05-25-17, Implementation: 05-25-17)
Provenance
- Source
- cms.gov
- Retrieved
- 2026-08-25
- Edition
- iom-2026-08-25
- Content hash
016e044721df1afa3c5c7dd130ba970556dae8affa9a23885a7fa7e2bedf7b08
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