January 8, 2020 News

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  • January 9, 2020


On December 10, 2019, CMS approved a new RAC audit – Issue Number 0171 Erythropoiesis Stimulating Agents for Cancer Patients: Medical Necessity and Documentation Requirements, this RAC audit will apply to all A/B MACs for physicians/non-physician practitioners and hospital outpatient claims. This RAC audit is a complex review, which almost always involves a request for medical records from the contractor. Under the audit issue description, CMS states, “Medical records will be reviewed to determine if the use of ESA in cancer and related neoplastic conditions meets Medicare coverage criteria. Affected Codes J0881 and J0885 that were billed with modifiers EA and EB.” Dates of service to be audited are claims having a “claim paid date” which is less than 3 years prior to the Demand Letter date.

The National Coverage Determination (NCD) for ESAs can be accessed here:

National Coverage Determination Manual, Chapter 1, Section 110.21: Erythropoiesis Stimulating Agents (ESAs) in Cancer and Related Neoplastic Conditions).


The transition to the new MBIs is now complete. Providers are required to use MBIs for all Medicare transactions including billing, eligibility status, and claim status. This applies to all services billed starting January 1, 2020 including services provided before this date with the following exceptions:

  • Appeals – You can use either HICNs or MBIs for claim appeals and related forms.
  • Claim status query – You can use the HICN or MBI to check the status of a claim (276 transactions) if the earliest date of service on the claim is before January 1, 2020. If you are checking the status of a claim with a date of service on or after January 1, 2020, you must use the MBI.
  • Span-date claims – You can use HICNs or MBIs for 11X-Inpatient Hospital, 32X- Home Health (home health claims and Request for Anticipated Payments [RAPs]) and 41X-Religious Non-Medical Health Care Institution claims if the “From Date” is before the end of the transition period (December 31, 2019). If a patient starts getting services in an inpatient hospital, home health, or religious non-medical health care institution before December 31, 2019, but stops getting those services after December 31, 2019, you may submit a claim using either the HICN or the MBI, even if you submit it after December 31, 2019. Since you submit home health claims for a 60-day payment episode, you can send in the episode’s RAP with either the HICN or the MBI, but after the transition period ends on December 31, 2019, you have to use the MBI when you send in the final claim that goes with it.

MLN Matters Number: SE18006 reminds providers to use the MBI the same way the HICN was used and to put the MBI in the same field where you always put the HICN. This also applies to reporting informational only and no-pay claims. Don’t use hyphens or spaces with the MBI to avoid rejection of your claim. After January 1, 2020 claims submitted with HICNs will be rejected with the following rejection codes:

  • Electronic claims- Reject codes: Claims Status Category Code of A7 (acknowledgment rejected for invalid information), a Claims Status Code of 164 (entity’s contract/member number), and an Entity Code of IL (subscriber)
  • Paper claims- paper notice; Claim Adjustment Reason Code (CARC) 16 “Claim/service lacks information or has submission/billing error(s)” and Remittance Advice Remark Code (RARC) N382 “Missing/incomplete/invalid patient identifier”


The American Hospital Association (AHA) successfully challenged CMS’ use of its authority to pay for certain outpatient clinic visit services provided at excepted off-campus PBDs at the same rate that CMS uses to pay non-excepted off-campus PBDs for those services under the Physician Fee Schedule.

CMS has been instructed by the court to immediately cease the clinic visit provided at excepted off-campus PBDs payment reduction for CY 2019. CMS installed a revised Hospital Outpatient Prospective Payment System Pricer to update the rates being applied to claim lines. The revised Pricer applies to claims with a line item date of service of January 1, 2019, and after.

In a recent MLN Matters article, CMS says they are working to ensure affected 2019 claims for clinic visits are paid consistent with the court’s order and starting January 1, 2020, and over the next few months, the Medicare Administrative Contactors (MACs) will automatically reprocess claims paid at the reduced rate; no provider action needed.

For more information on this issue read the MLN Matters December 19, 2019 Issue: https://www.cms.gov/outreach-and-educationoutreachffsprovpartprogprovider-partnership-email-archive/2019-12-19#_Toc27549718


Effective January 1, 2020, Bind Benefits, an on-demand health insurance available through self-insured employers, will be available to all UnitedHealthcare (UHC) employer groups across the nation. According to UHC, Bind accesses UnitedHealthcare networks and contracts and referrals are not required for Bind members. Bind members will have a member ID card that easily identifies the plan.

Under Bind Benefits, there are no annual deductibles, patients pay flat-dollar copayments for a core set of medical services. However, according to a recent article from Kaiser Health News (KHN), add-in services (services that are not covered as part of the core set of medical services) will result in additional premiums. These add-in premiums paid by patients will vary depending on whether the patient chooses lower-cost providers or more expensive ones.

Importantly, premiums (including any add-in premiums) don’t apply to the Affordable Care Act’s (ACA’s) out-of-pocket maximums. Out-of-pocket maximums in 2020 are $8,150 for self-only coverage, and $16,300 for family coverage.

The January 2020 UHC Bulletin includes information on this new health insurance plan and illustrations of the Bind on-demand health insurance card.



The North Carolina Blue Cross Blue Shield myChoice policies limit reimbursement to physicians and hospitals for services provided to 40% above what Medicare would pay. According to the myChoice website, the plan is more affordable and puts patients in control of their health care. myChoice has no network of doctors and hospitals so patients are free to see any provider. However, that means that patients must find providers who are willing to accept the reimbursement amount, or risk being balance-billed by providers that don’t accept the flat payment the plan pays.

The myChoice website includes this notice about balance billing:

  • For covered medical services, myChoice will pay 100% of the maximum allowable cost once you meet your deductible.
  • Keep in mind that providers may charge more than the maximum allowable cost. In this case, you will receive a bill for the difference (called “balance billing”), which it will be your responsibility to pay.
  • Balance billing amounts will not apply to your deductible or maximum out-of-pocket.

The myChoice plan is available to individuals who buy their own insurance and small businesses with one to 50 employees.

 Oplinc would love to hear about your experiences with Bind Benefits, BCBS My Choice or any other new non-traditional health plans – email us at Rise@oplinc.com with your comments. Please do not send any patient specific information.


Oplinc has partnered with Oncology Supply/ION to provide the Oplinc Fast Facts to cancer clinics since 1999. We are so grateful for the support that Oncology Supply/ION provides in sponsoring this publication and for their support of community oncology as a whole.


Oplinc wants to thank Genentech for their sponsorship of Oplinc’s Best Practices Review Newsletter in 2020! The Quarter 1, 2020 Oplinc Best Practices Review newsletter will be arriving in your inboxes soon.