MSP Situations Under CAP

40.7.7 - MSP Situations Under CAP (Rev. 11550; Issued: 08-12-22; Effective: 10-13-22; Implementation:10-13-22) Providers who elect into the CAP voluntarily agree to obtain CAP drugs for Medicare beneficiaries exclusively through an approved CAP vendor. In situations where participating CAP providers obtain a drug from the CAP vendor for a beneficiary who is incorrectly determined to have Medicare as their primary insurer, but the provider and the CAP vendor must first bill the appropriate primary insurer for the drug and the administration service. Upon receipt of the primary insurer’s payment, MSP claims should then be submitted by the physician to their A/B MAC (Part B) for the administration service and by the approved CAP vendor to the CAP designated A/B MAC (Part B) for the drug. Providers are required to submit MSP claims even if they believe there is no outstanding balance due. Such claims must adhere to CAP guidelines and include the drug HCPCS code, the prescription number provided by the approved CAP vendor and an appropriate CAP no- pay modifier. Approved CAP vendor claims must also adhere to CAP requirements and include the assigned prescription number. All participating CAP providers to submit MSP claims for drug administration services where the drug was obtained from the approved CAP vendor. Failure to submit an MSP claim for the drug administration prevents the processing of the vendor’s MSP claim by the CAP designated A/B MAC (Part B). Drugs Obtained Outside of the CAP for Beneficiaries with Medicare In certain rare situations, participating CAP providers may mistakenly obtain drugs for Medicare beneficiaries outside of the CAP vendor because they had determined that the beneficiary had another insurer that was primary to Medicare. In order to make an appropriate payment for drugs administered under these unusual circumstances, we are allowing temporary use of the J3 modifier to bypass CAP edits and pay the participating CAP provider at the current ASP rate.