CMS Pub. 100-04, ch. 17, § 101.1

The CAP designated A/B MAC (B) has responsibility to deliver dispute resolution

services to the approved CAP vendor when the approved CAP vendor’s drug product

claims are not paid because the participating CAP physician has either failed to file a

payable drug administration claim or has failed to file a successful appeal of the denied

drug administration claim.

The approved CAP vendor may file its drug product claim on the day it delivers the drug

to the participating CAP physician. The participating CAP physician is contractually

obligated to file his or her CAP drug administration claim within 14 days of

administering the drug.

The approved CAP vendor may determine its own threshold for financial exposure. If

the approved CAP vendor does not receive payment within 14 days, then the approved

CAP vendor may request assistance from the CAP designated A/B MAC (B) in

encouraging the participating CAP physician to fulfill his or her contractual obligations.

If the CAP designated A/B MAC (B)’s dispute resolution services do not yield adequate

results for the approved CAP vendor, then the approved CAP vendor may request that the

CAP designated A/B MAC (B) investigate the participating CAP physician’s

performance and recommend that the participating CAP physician’s CAP election

agreement be terminated. If the CAP designated A/B MAC (B) does recommend

termination, then a suspension, hearing, and final termination process set forth in 42 CFR

414.916 will be employed by CMS.