CMS Pub. 100-04, ch. 17, § 101

Instructions on Special CAP Appeals Requirements and Delivery of

Dispute Resolution Services

(Rev. 1076, Issued: 10-13-2006; Effective: 07-01-06; Implementation: 11-13-06)

All appeals of denied CAP claims will be processed by the local A/B MAC (B). This

includes an appeal for the denial of an approved CAP vendor’s drug product claim. This

break from the traditional administrative appeals process is necessitated by the

arrangement whereby the CAP designated A/B MAC (B) pays the approved CAP vendor

claim only after a match is found in the central claims processing system indicating the

corresponding participating CAP physician’s drug administration claim was paid by the

local A/B MAC (B). As a result, the only appealable issues attach to the decision of the

local A/B MAC (B).

The CAP claims processing arrangement departs from the standard Part B claims

processing routine. The A/B MAC (B) will make an initial determination on whether the

participating CAP physician’s claim for drug administration is payable by applying local

coverage determinations (LCDs) to the administration and to the drugs billed as no-pay

on the claim. If the A/B MAC (B) finds the no-pay or administration lines are contrary to

the LCDs, it will deny the administration and pass on a non-approved indicator on the no-pay lines. The A/B MAC (B) sends a pay process indicator to CWF for each of the no-pay lines. When the designated A/B MAC (B) enters the vendor claim into the system,

CWF looks for a match. When CWF goes to find the match, it will not match against

non-approved lines. If it finds a match among the approved lines, then it lets the

designated A/B MAC (B) know and the claim is paid. If it doesn’t find a match, the

claim recycles for 90 days. Periodically during the 90 days, the designated A/B MAC

(B) looks for a match again. If it finds one, the claim pays. If after 90 days it doesn't find

a match, then the claim denies. The A/B MAC (B) will notify CWF whether the

approved CAP vendor’s claim for the drug is payable. If the vendor’s claim is not

payable because of a determination of the A/B MAC (B), then the designated A/B MAC

(B) will be notified. In turn, the designated A/B MAC (B) will deny the approved CAP

vendor’s claim. The claims processing requirements for this process have been described

in previous CAP Change Requests.

Because the A/B MAC (B)’s initial determination on the drug administration claim

decides the outcome of the of the approved CAP vendor’s drug product claim, CMS

interprets the initial determination to be an initial determination of the approved CAP

vendor’s drug product claim for the purposes of the Part B appeals regulations found at

42 CFR 405.801. Accordingly, the approved CAP vendor shall not file its appeal with

the CAP designated A/B MAC (B). Rather, the approved CAP vendor shall file its

appeal with the A/B MAC (B), with one exception.

That exception is the case where the approved CAP vendor’s drug product claim was

denied because there was no matching claim filed by the participating CAP physician

after 90 days of recycling. In this instance, the designated A/B MAC (B) will deny the

approved CAP vendor’s drug product claim and suppress appeal rights. The remittance

notice will instruct the approved CAP vendor that it may request a reopening. Upon

receipt of a reopening request, the designated A/B MAC (B) will contact the participating

CAP physician and request that he or she fulfill his or her CAP participation agreement

by filing the drug administration claim. If the participating CAP physician does not

follow through as required, then the designated A/B MAC (B) will initiate the dispute

resolution track discussed below.

In the role of the furnishing Medicare supplier, the approved CAP vendor is a party to

any appeal of a denied drug administration claim filed by a participating CAP physician

with the A/B MAC (B). The balance of the rules pertaining to the A/B MAC (B)’s

adjudication of Part B appeals applies (See Pub. 100-04, Chapter 29), with the following

exceptions:

a) The A/B MAC (B) will check for duplicate appeals. If the participating CAP

physician and the approved CAP vendor filed independent appeals connected with

the same service, then the A/B MAC (B) will merge the two files.

b) The A/B MAC (B) will ensure the approved CAP vendor is copied on all

correspondence connected with the participating CAP physician’s appeal of the

denied drug administration claim.