Local contractor pricing

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Home ► Fee news ► Local contractor pricing

Last Modified: 2/22/2024 Location: FL, PR, USVI Business: Part B

Local contractor pricing

First Coast allowances for not-otherwise classified (NOC) drugs that have not been priced by CMS are typically paid using 106% or 103% of the average wholesale price (AWP), depending on the year. If there is no published AWP, then we would pay based on invoice. The only NOC that CMS has not priced that we pay outside of this criterion at this time is Intravitreal Avastin.

1. When receiving an additional documentation request (ADR) for a drug code billed on a claim that is requesting an invoice for payment, what should we submit?

• You should submit the invoice received from the pharmacy or manufacturer showing the drug cost.

2. I sent First Coast the invoice. Why did the drug claim line deny?

The main reasons drug claim lines may deny are:

• The provider sends only the office note or medical record and does not send the actual drug invoice showing the cost. While the medical record assists the First Coast clinical staff in verifying the medical necessity for the drug administered, it does not provide the necessary drug cost information for the First Coast clinical staff to determine payment.

• The provider sends the office superbill. This only shows the First Coast clinical staff what the provider's office charges are for the drug. It does not show the actual cost the provider paid for the drug from the pharmacy/supplier.

• The provider sends in only the packing slip for the drug. In most cases, the packing slip lists only the drugs packaged in that shipment and the quantity shipped and does not show the actual cost for each drug. You must send the invoice showing the actual cost of the drug for the First Coast clinical staff to determine payment.

• The provider sends in an invoice with drug pricing, but the drug in question is not on the invoice. You must send the invoice for the drug listed on the ADR for the First Coast clinical staff to determine payment.

3. What information needs to be in block 19 of the 1500 claim form or electronic equivalent when submitting a claim for a new drug? (applicable to Part B only)

When submitting a claim for a new drug, please report the name of the drug and dosage administered in block 19 of the 1500 claim form or electronic equivalent, Loop 2400 Segment NTE02.

4. Where can I find if a code that has payment by Medicare?

The easiest way to find a code and determine payment by Medicare is to visit the fee schedule page on our website. You can search for the specialty fees on our fee schedule page, which includes information on other services, such as ambulance, clinical laboratory, etc. If you cannot find a fee or information regarding the coverage of a service or procedure code, contact customer service at 866-454-9007.

5. How often are the contractor priced fees reconsidered?

We evaluate contractor priced fees on an annual basis or more frequently when revised cost (wholesale acquisition cost, average wholesale price, etc.) information is received.

See local coverage article A59576, Billing and Coding: Approved Drugs and Biologicals; Includes Cancer Chemotherapeutic Agents external link

for additional guidance.

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