Oplinc

This latest edition of the Best Practices Review newsletter focuses on patient assistance services and resources that may be available to your patients as well as practical information for your business department.

Patient Assistance Resources 2007

Access the archived Best Practices Review newsletters on the Publications page.

Welcome to Oplinc

Oplinc is a national organization that was founded with the purpose of developing a collaborative environment within the oncology community.

Oplinc is dedicated to preserving patients’ access to cancer services through the facilitation of education, communication and networking between physicians, pharmaceutical manufacturers and payers involved in the delivery of quality cancer care.

5/16/2008
Medicare ESA Requirements

In response to requests for clarification on the reporting requirements for ESAs and other anti-anemia drugs, and to reports of incorrect denials on these drugs I have summarized the billing requirements and included an ESA Required Information Reference Chart.

Remember, the information in the link below pertains to the CMS requirements, your Medicare Contractor may have additional billing and reporting requirements. Refer to your Medicare Contractors Web site and bulletins for updated information.

Summary of ESA Billing & Reporting Requirements and Reference Chart

If your ESA claims are being incorrectly denied:

1. Verify that you are including all of the required information on your claims in the right format and in the right field see the Reference Chart below and review your Carriers guidelines.

2. Contact your software vendor to make sure the information is being mapped properly to Loop 2400 MEA segment on the electronic form 837P or item 19 of the paper CMS 1500 for the hct/hgb, and the correct line item corresponding to the ESA HCPCS for the ESA modifiers.

3. Verify that the information is being transmitted properly from your practice management billing system or billing service to the clearinghouse.

4. Verify that the information is being transmitted properly from the clearinghouse (or your software system if you are transmitting directly to Medicare) to your Medicare Contractor. Remember the recent issue where CMS reported that some clearinghouses were inadvertently removing the NPI before transmitting the claim to Medicare.

5. Verify that the Medicare Contractor is receiving the required information – you can call your Contractor’s EDI support line to verify that the information is going over properly in the correct field.

Finally, if all of the information is in the correct format and field and is being transmitted properly to your Medicare Contractor the problem may be a systems problem with your Medicare Contractor. If you find this to be the case, contact your state oncology society to make them aware of the problem.

This communication is for informational purposes only. Medicare regulations are constantly evolving, consult your Medicare carrier, contracted insurers & state laws for specific guidelines on billing and reimbursement.