US · guidance
CMS Pub. 100-04, ch. 17, § 100.5
Matching the Physician Claim to the Vendor Claim
CWF shall match physician submitted claim lines with prescription numbers and no-pay
modifiers to vendor submitted claim lines with prescription numbers.
The A/B MAC (B) shall send to CWF a pay/process indicator for each line of the claim,
(including the lines with HCPCS codes for the administration of the CAP drug and the
lines for the CAP drug HCPCS code), to indicate whether it is approved, not-payable due
to medical necessity, or not payable due to a reason other than medical necessity.
When CWF finds a prescription number that matches a prescription number on the claim,
it shall notify the designated A/B MAC (B). The designated A/B MAC (B) shall make
payment for the drug lines that have a pay/process indicator of approved. It shall deny
any lines not approved.
History
(Rev. 866, Issued: 02-17-06, Effective: 07-01-06, Implementation: 07-03-06)
Provenance
- Source
- cms.gov
- Retrieved
- 2026-08-25
- Edition
- iom-2026-08-25
- Content hash
623d12cd69baba88530141da74b9da62f6ddb726a924f74c1ad6054a582f5848
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