CMS, Palmetto/J1MAC, & UHC News

The following information has been received by ANCO.


****CMS NEWS****
MM6407 – Medicare Claims Processing Manual Clarifications for Skilled Nursing Facility (SNF) and Therapy Billing
http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM6407.pdf


CMS has made available the Medicare Part B Drug and Biological Average Sales Price (ASP) Payment Amounts for April 1, 2009 to June 30, 2009 on the CMS website at http://www.cms.hhs.gov/McrPartBDrugAvgSalesPrice/01a1_2009aspfiles.asp. The files are located in the "Downloads" section of this web page. Revised pricing files for January 2009, October 2008, July 2008 and April 2008 are also available for download. The 2008 revised pricing files are posted at http://www.cms.hhs.gov/McrPartBDrugAvgSalesPrice/01a_2008aspfiles.asp.


****PALMETTO/J1MAC NEWS****
Access Unavailable during Significant System Updates This Weekend
http://www.palmettogba.com/palmetto/providers.nsf/DocsCat/Providers~Jurisdiction%201%20Part%20A~Access%20Unavailable%20during%20Significant%20System%20Updates%20This%20Weekend?opendocument

If the above link does not work in your e-mail program, please use the
temporary alternate link provided below.
http://www.palmettogba.com/palmetto/providers.nsf/docsCat/8525746A00550AA38525758900668577?opendocument

This weekend significant system updates are being implemented. The system
will go down at 7 p.m. PST on Friday, April 3, 2009. While updates are
being deployed, you may be unable to access claims information through the
IVR. Claims information will, once again, be obtainable on Monday, April 6,
2009.

April 2009 J1 A/B MAC Medicare Advisory
http://www.palmettogba.com/palmetto/providers.nsf/DocsCat/Providers~Jurisdiction%201%20Part%20A~Publications~Medicare%20Advisory~April%202009%20J1%20AB%20MAC%20Medicare%20Advisory?opendocument

If the above link does not work in your e-mail program, please use the
temporary alternate link provided below.
http://www.palmettogba.com/palmetto/providers.nsf/docsCat/8525746A00550AA385257589004DD7B4?opendocument

The April 2009 J1 A/B MAC Medicare Advisory is now available to be viewed
on the Palmetto GBA Web site. It contains the latest updates and useful
information regarding Medicare. Please share this information with your
staff.

CMS Quarterly Provider Update
http://www.palmettogba.com/palmetto/providers.nsf/DocsCat/Providers~Ohio%20Part%20B%20Carrier~Articles~General~CMS%20Quarterly%20Provider%20Update?opendocument

If the above link does not work in your e-mail program, please use the
temporary alternate link provided below.
http://www.palmettogba.com/palmetto/providers.nsf/docsCat/8525746A00550AA385256D3400525573?opendocument

The Quarterly Provider Update is a comprehensive resource published by the
Centers for Medicare & Medicaid Services (CMS) on the first business day of
each quarter. It is a listing of all non-regulatory changes to Medicare
including Program Memoranda, manual changes, and any other instructions
that could affect providers. Regulations and instructions published in the
previous quarter are also included in the Update.


****UHC NEWS****
KRAS gene requirement for cetuximab and panitumumab in colorectal cancer

Effective April 1, 2009, UnitedHealthcare will require the submission of a pathology report documenting a wild type KRAS gene for coverage of Erbitux® (cetuximab J9055) and Vectibix® (panitumumab J9303) in the treatment of metastatic colorectal cancer. As always, final coverage is subject to the member’s benefit plan document.

UnitedHealthcare has contracts with two national laboratories (Genzyme Genetics and LabCorp) that provide KRAS testing. Specimens may be sent directly to these laboratories; claims for members that are paid on a fee for service basis (non capitated) will be paid directly to the laboratories by UnitedHealthcare. Both laboratories request that a copy of the pathology report be sent with the specimen. If your local participating laboratory provides this test it will also be covered.
Requirements:

The submission of a KRAS pathology report is required for members starting therapy using cetuximab or panitumumab after the implementation date. Only one pathology report per member ID is required.
Physicians will not be required to submit pathology reports for individuals that were on cetuximab or panitumumab prior to the effective date for the plan's policy.

The policy applies to those individuals where UnitedHealthcare or one of its affiliated entities is the primary payor.

Pathology reports are NOT required if UnitedHealthcare or one of its affiliated entities is the secondary payor.

For UnitedHealthcare patients: Fax a copy of the pathology report to (915) 231-1970 using the KRAS fax coversheet. The coversheet is available at UnitedHealthcareOnline.com >Cancer - Oncology > KRAS > KRAS Fax Coversheet. You may use this process and submit your claims electronically.

For Oxford patients: Oxford will also require the KRAS pathology report for individuals starting cetuximab and panitumumab therapy 4/1/09. Providers are required to obtain prior authorization for the use of cetuximab and panitumumab for patients with colorectal cancer. Prior authorization requirements include the submission of the laboratory report demonstrating the presence of the KRAS wild type gene. Providers should follow the standard prior authorization process.

Additional information regarding the implementation of this policy for UnitedHealthcare and its entities is available at UnitedHealthcareOnline.com and on the other health plan websites.

Lee Newcomer comments: UnitedHealthcare had a similar process for the HER2 gene and trastuzumab coverage. During the two years the edit was active we noted that the billing offices frequently sent the wrong clinical records. We only need the copy of the laboratory report documenting the KRAS gene type. Please do not send pathology reports, clinic notes, discharge summaries or other unrelated materials. It may be beneficial for the clinicians to teach the billing staff what document to send for this review.


Access to the NCCN Compendium for UnitedHealthcare coverage

The National Comprehensive Cancer Network (NCCN) has announced that effective April 1, 2009 they will require a paid subscription for access to the NCCN Drugs and Biologics Compendium. As you already know, UnitedHealthcare uses this document as a reference for coverage decisions.

UHC recognizes the value of the NCCN Drugs and Biologics Compendium in physician practices and has purchased a group rate. We are pleased to offer FREE access to the NCCN compendium to our UHC participating physicians and their office staff.

To access the NCCN Drugs and Biologics Compendium under the UHC agreement, you will need to be a registered user of UnitedHealthcareonline. Once you are logged into our website, proceed to the NCCN Compendium page. From there, you can log in to www.NCCN.org for free access to the NCCN Drugs and Biologics Compendium.

If you are not a registered user of UnitedHealthcareonline, go to the New User link in the upper right corner of the home page and register.