New Pricing Methodology for LARCs and Vaccines

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 thereafter. 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% and Vaccines will be priced at WAC plus 3%. Since this new pricing method is effective July 1, 2017, a future reprocessing effort for these claims may be performed. Any details regarding reprocessing will be communicated in a future announcement.

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 as the new pricing is based on a procedure code/NDC match. If the procedure code/NDC combination is not found, the claim line will deny and post EOB 02047: "RATE NOT 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 Pharmacy and Professional claims. Please contact Myers and Stauffer with any questions or concerns; NCTracks will not be able to assist with these issues.

Secondary claims will continue to price using the lesser of logic and all existing QMB rules.