The Cures Act and clarification
Payment for a charge for services by a non-institutional healthcare provider for which a claim is submitted to TRICARE, shall be equal to an amount, determined to be appropriate, to the extent practicable, in accordance with the same reimbursement rules as apply to payments for similar services under the Social Security Act.
The TRICARE benefit for home infusion service is robust:
- TRICARE will cost-share many additional home infusion drugs, along with their required supplies and services, in accordance with TRICARE policy
- TRICARE covers the associated services (e.g., skilled nursing) required for the administration of medically necessary home infusion drugs, thereby ensuring full reimbursement of all medically necessary care
- TRICARE leverages the expertise and capacity of our pharmacy contractor to provide home infusion drugs that are appropriate for ongoing self-administration
Because TRICARE is mandated by law, to the extent practicable, to pay like Medicare, Medicare’s reimbursement methodology for home infusion drugs delivered through DME has been adopted as the TRICARE Maximum Allowable Charge, reflective of the revisions made by the 21st Century Cures Act.
Network agreements may impose certain negotiated rates or other reductions to this methodology in accordance with the terms of the agreement.
Recurring billing errors
- Use of miscellaneous “J” codes (e.g., J3490, J3590, and J9999) when specific “J” codes are available
- Non-compliance with billing guidelines (e.g., paper CMS-1500 or electronic HIPAA 837)
- Entry of NDC quantities in the HCPCS quantity field
- Failure to provide the NDC number
- Failure to provide the NDC Unit of Measure
- Failure to provide the NDC Quantity
Guidelines for timely and accurate claims resolution and payment
A. NDC field: Each NDC must be reported as an 11-digit code unique to the manufacturer of the specific drug or product administered to the patient, using a 5-4-2 format (i.e., 5 digits, followed by 4 digits, followed by 2 digits) 99999999999.
B. NDC units/quantity field: The quantity of each submitted NDC must be a numeric value greater than zero. In most cases, the NDC quantity will be different from the HCPCS billed units. To determine the correct NDC quantity, refer to the data column titled CF (conversion factor) on the Noridian Crosswalk Table. This table is updated monthly by CMS.
Identify your "J" or "S" code and correlating NDC# for your combination record, divide the number of billed HCPCS units by the CF; and enter the resulting number as the NDC Quantity.
Whenever a miscellaneous "J" or "S" code is used, the CF is NOT valid. In these cases, your entry of the NDC Quantity is the sole source of quantity to be priced based on the ASP.
"J" or "S" HCPCS Quantities must always be stated in "whole" numbers. NDC quantities can be stated in up to three places to the right of the decimal. When pricing, the NDC Quantity is “rounded” to the nearest “whole” number.
C. NDC measurement (package/unit Indicator) field: The unit of measurement for each NDC must be submitted. Noridian Crosswalk Table assumes the conversion of units NOT packages. If using the conversion factor on the Noridian Crosswalk Table, the unit of measurement should always be submitted as "units". (UN, ML, or GR for electronic HIPAA 837 and "U" for paper CMS-1500 claims).
If you are one of the many providers enjoying the benefits of electronic claim filing, the following data elements should be used to submit the NDC information in the HIPAA-standard ASC X12 837 claims format:
- LIN03-product/service-NDC (11-digit format)
- CTP04-NDC units (must be numeric value greater than 0 (up to 3 decimal places allowed)
- CTP05-1-NDC unit of measurement UN, ML, GR (priced as units) or F2 (priced as a package - you should avoid using the F2 value if possible)
When filing claims for home infusion medications:
- Make sure the NDC number, units, and unit of measurement are listed on the gray line above the HCPCS code if you are filing using a CMS-1500 claim form
- Report the NDC number in the 11-digit format
- Use the Noridian Crosswalk Table to convert the HCPCS units into NDC units
- Submit the UOM as units (UN, ML, or GR)
- Place of service must be "home"
- If Infusion therapy is performed in an Ambulatory Infusion Suite, place of service must be “office” and the HCPCS must be submitted with modifier "SS"