CMS Pub. 100-04, ch. 23, § 40.4.1

(HHH)

(Rev. 1, 10-01-03)

CMS Memo 9-13-02 HCPCS Gap-fillR3.doc

Any A/B MAC (B) that establishes a HCPCS gap fill payment rate for its own use, or at the request of an

A/B MAC (A) or (HHH), must forward the information to the contacts at all A/B MACs (A) or (HHH) with

providers in the A/B MAC (B) service area.

A/B MACs (B) that establish HCPCS gap-fill payment rates for their own needs should forward the

information to A/B MACs (A) and (HHH) as soon as practicable. A/B MACs (A) and (HHH) are to contact

the appropriate A/B MAC (B) to request a gap fill payment rate with 5 working days of the suspension of

claims containing HCPCS codes(s) for which payment rate is needed and has not been forwarded. A/B

MACs (B) must provide the payment rate to the requesting A/B MAC (A) or (HHH) (and all other A/B

MACs (A) or (HHH) with providers in that common jurisdiction) within 10 working days of receipt of the

request.

Requests for policy clarification in A/B MAC (B) establishing the HCPCS gap fill payment rates or A/B

MAC (A) or (HHH) procedures for the use thereof should be directed to the respective Regional Office

HCPCS business function experts (BFE). Examples of the need for A/B MAC (A) or (HHH) consultation

with the BFE are coverage questions and receipt of unresolved significant inconsistencies in fee amounts

from different A/B MACs (B) for the same HCPCS. The A/B MAC (A) or (HHH) should consult the A/B

MACs (B) with disparate fees before contacting the BFE.

An A/B MAC (A) or (HHH) experiencing delay in replies or nonresponses from an A/B MAC (B) should

alert it respective Consortium Contractor Management Staff (CCMS) Contract Manager (CM). The CM

will coordinate with his/her counterpart assigned to the A/B MAC (B) to achieve more timely action by the

A/B MAC (B).

It is the A/B MAC (A)’s or (HHH)’s responsibility to ascertain the amount or consult with the A/B MAC

(B), CCMS-CM, or BFE timely. A/B MAC (A or (HHH) requests to apply CC 15 to claims which are paid

untimely solely because of a delay in ascertaining a HCPCS gap fill amount from the A/B MAC (B) should

be addressed to the respective CM. The CM will contact the HCPCS BFE for a decision. Requests for

application of CC 15 to claims for which the A/B MAC (A) or (HHH) did not request the gap fill payment

rate within 5 working days of the claim suspension and/or did not seek timely advice from the RO BFE

concerning application of gap fill amount will not be honored. Additionally, if the A/B MAC (B) replied at

least five days before the expiration of the payment floor, CC 15 requests will not be honored.