Matching the Physician Claim to the Vendor Claim

100.5 - Matching the Physician Claim to the Vendor Claim (Rev. 866, Issued: 02-17-06, Effective: 07-01-06, Implementation: 07-03-06) 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.