Creation of New Reimbursement Methodology for Clotting Factor Products

On April 29, 2018, to comply with the requirements of CMS 2345-FC, a new methodology for reimbursing providers for hemophilia/clotting factor products will be implemented. This new reimbursement methodology will be used for clotting factor products on Professional and Pharmacy Point of Sale (POS) claims.

Current hemophilia pharmacy claims pricing methodology for single ingredients and compounds will be retroactively end-dated to March 31, 2017. Two (2) new pricing methodologies related to hemophilia drugs will be added to the pharmacy claims pricing effective with date of service April 01, 2017, which are the 340B Ceiling Price for 340B Hemophilia Treatment Centers and Average Acquisition Cost (AAC) non-340B price. Pharmacy claims reimbursement rates will include a Professional Dispensing Fee calculated per unit of drug dispensed, as well as Ingredient Cost.

If a Pharmacy price cannot be determined, then EOB message 00325 will post the following instruction, "NO HEMOPHILIA DRUG PRICE FOUND. CONTACT THE M&S HELPDESK AT (1-800-591-1183) or email at ncpharmacy@mslc.com ." Myers and Stauffer (M&S) is the current actuary who maintains these drug prices for these Pharmacy and Professional claims. Please contact M&S with any questions or concerns (NCTracks will not be able to assist with these issues).

Professional claims pricing methodology will be modified to do a look up on the drug price using the National Drug Code (NDC) submitted on the claim line for blood clotting factor products. A combination of the HCPCS code and the NDC will be used to determine the price for these clotting factor products. The provider submission of the 'UD' modifier will determine if a claim line is priced as 340B or if absent, AAC. Professional claims will not receive the additional calculated dispensing fee.

If a Professional price cannot be determined then new EOB message 02047 will post the following instruction, "RATE NOT FOUND. CONTACT THE M&S HELPDESK AT (1-800-591-1183) or email at ncpharmacy@mslc.com ." Please contact M&S with any questions or concerns (NCTracks will not be able to assist with these issues).

Future communications will be provided regarding any reprocessing of claims related to this change.