Claims Processing Jurisdiction for Oral Anti-Emetic Drugs

80.2.2 - Claims Processing Jurisdiction for Oral Anti-Emetic Drugs (Rev. 2931, Issued: 04-15-14, Effective: 05-29-13, Implementation: 07-07-14) The following chart shows which drugs are billed to the A/B MAC (A) or (B) and which drugs are billed to the DME MAC. Per the Balanced Budget Act of 1997, effective for claims with dates of service on or after January 1, 1998, the claims processing jurisdiction rules in Chart 1 apply. Effective July 1, 2006, claims from institutional (hospital) pharmacies are also billed as shown in this chart. CHART 1 COMBINATION JURISDICTION Oral anti-cancer chemotherapy drug with oral anti-emetic drug DME MAC maintains processing responsibility for the National Drug Code (NDC) oral anti-cancer chemotherapy drug and the K0415 oral anti-emetic drug code combinations. DME MAC processes the NDC oral anti-cancer chemotherapy drug and Q code oral anti-emetic drug(s) when provided in the physician’s office. A/B MAC (A) processes the 3-drug combination anti- emetic (Aprepitant) in the form of a Tri-Pak when dispensed by a hospital. A/B MAC (A) processes the initial days’ supply of the 3- drug anti-emetic combination when a hospital dispenses it and writes a prescription for the second and third days’ supply. DME MAC processes the second and third days’ supply of the 3-drug anti-emetic combination. DME MAC processes the NDC oral anti-cancer chemotherapy drug and/or Q code oral anti-emetic drug(s) when supplied by a pharmacy, including a hospital pharmacy. Oral anti-cancer chemotherapy drug with rectal anti-emetic drug DME MAC maintains responsibility for processing both the NDC oral anti-cancer chemotherapy drug and the K0416 rectal anti-emetic drug. Oral anti-cancer chemotherapy drug with intravenous anti-emetic drug DME MAC maintains responsibility for processing the NDC oral anti-cancer chemotherapy drug and the A/B MAC (B) or A/B MAC (A) for processing the intravenous anti-emetic J code drug(s). Intravenous anti-cancer chemotherapy drug with oral anti-emetic drug A/B MAC (B) processes the intravenous J code anti- cancer chemotherapy drug. The oral anti-emetic Q code drug(s) is processed by the DME MAC when provided in the physician’s office, hospital, or when provided by a supplier. Intravenous anti-cancer chemotherapy drug with intravenous anti-emetic drug A/B MAC (B) processes both intravenous anti-cancer chemotherapy J code drug and intravenous anti-emetic J code drug(s). Providers (HIPAA definition) that bill the DME MAC require a supplier number issued by the National Supplier Clearinghouse (NSC) in order to submit claims. A/B MACs (A) and (B) should instruct providers without a supplier number to contact the NSC service center at 1-866-238-9652 to request an enrollment package for a supplier number. Alternatively, providers may go to the CMS Web site, http://www.cms.gov/Medicare/Provider-Enrollment-and- Certification/MedicareProviderSupEnroll/EnrollmentApplications.html and download the Form CMS- 855-S in Adobe Acrobat format. The application can be completed hard copy and submitted to the NSC.