Author: Provider Reimbursement
On April 29, 2018, a new reimbursement methodology will be implemented for medical claims for physician-administered Long Acting Reversible Contraceptives (LARCs) and vaccines, effective for claims with date of service July 1, 2017 and after. The changes will impact professional claims, dialysis claims and all claim types for LARCs and vaccine procedure codes.
Claims for physician administered LARCs will be priced at Wholesale Acquisition Cost (WAC) plus 6 percent and vaccines will be priced at WAC plus 3 percent. Since this new pricing method is effective July 1, 2017, a future reprocessing effort for these claims may be performed. Details regarding reprocessing will be communicated in a future announcement.
The new pricing is based on a procedure code/National Drug Code (NDC) match. Therefore, all providers are required to submit the appropriate NDC that corresponds to the physician administered LARCs and vaccines used for administration and corresponding procedure code. If the procedure code/NDC combination is not found, the claim line will deny with Explanation of Benefit (EOB) 02047:
- RATE NOT FOUND OR PROCEDURE/NDC XWALK DOES NOT EXIST. CONTACT THE M&S HELPDESK AT (855) 457-5264.
Secondary claims will continue to price using the lesser of logic and all existing Qualified Medicare Beneficiary (QMB) rules.
Provider Reimbursement
DMA, 919-814-0060