CMS/Medicare: Medicare Part B Drugs and Biologicals Competitive Acquisition Program (CAP): Post Payment Review and Medical Record Requests

The post-payment review process for the CAP is conducted to verify drug administration for Medicare claims submitted by an Approved CAP Vendor. For this process, a small sample of physician and Vendor claims and other documentation is examined in order to establish that drugs billed by an Approved CAP Vendor were administered and were medically necessary.

To support this review, participating CAP physicians may receive a request for copies of medical records from the CAP designated carrier, Noridian Administrative Services (NAS). Medicare requirements and the CAP Terms of Agreement require participating CAP physicians to submit all information necessary to support the services billed on claims.

Participating CAP physicians must submit medical records to NAS within the requested timeframe. This submission should include the patient’s drug administration record and all other records supporting medical necessity for the drug.

If CAP post payment review activity cannot establish that a drug was administered, then the vendor’s drug claim will be denied. The associated physician drug administration claim will also be referred to the physician’s local carrier for review and recoupment as necessary.

For additional information on the post payment review process, please visit NAS’s website at https://www.noridianmedicare.com/cap_drug/index.html.