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Revising a contractor fee

What we need

  • To reconsider a contractor developed fee, it is necessary to provide supporting documentation that was not available at the time of our initial decision. Relevant materials are suggested below.
  • The current fee will remain in place when a request does not provide compelling information.
  • Forward your request and the necessary information to medicalaffairs@guidewellsource.com
Code types Supporting documentation

Category I -  Examples: 15011, 15012, 15013, etc. 

OR

Category III -  Examples: 0202T, 0338T, etc.
  • Education about the procedure
  • Physician time involved
  • Level of physician effort
  • Direct cost
  • Indirect costs
    • Additional supplies or device
  • Product life expectancy
  • Random clinical trial (RCT) results
  • Published literature
Clinical laboratory and proprietary laboratory analyses (PLA) - Examples: 0581U, 0585U, etc. 
  • Education about the procedure
  • Direct costs
    • Labor costs
    • Capital equipment costs
    • Goods cost
  • Indirect costs
  • Summary of sample processing
  • Algorithm involvement
  • Random clinical trial (RCT) results
  • Published literature
Drugs, biologicals, and biosimilars - Examples: J0207, J0567, Q5157, etc.
  • Change in average wholesale price (AWP) or wholesale acquisition cost (WAC)
  • Change to code descriptor
HCPCS - Examples: G0555, G0564, G0565, etc.
  • Education about the procedure
  • Physician time involved
  • Level of physician effort
  • Direct costs
  • Indirect costs
    • Additional supplies or device
  • Random clinical trial (RCT) results
    • Published literature
Radiopharmaceuticals - Examples: A9513, A9515, etc.  
  • Change in average wholesale price (AWP)
  • Change to code descriptor    


References
•    CMS ASP Pricing Files
•    CMS IOM Pub. 100-04 Medicare Claims Processing Manual, Chapter 12, section 20
•    CMS IOM Pub. 100-04 Medicare Claims Processing Manual, Chapter 17
•    Understanding local pricing