Medicare-Based Fee Effective Dates - Medicare Advantage

Policy No: 114
Originally Created: 07/01/2012
Section: Administrative
Last Reviewed: 08/01/2024
Last Revised: 09/01/2022
Approved: 08/08/2024
Effective Date: 09/01/2024
Policy Applies To: Medicare Advantage

This policy applies to all physicians, other qualified health care professionals, hospitals, and other facilities.

Average Sales Price (ASP) - A statutorily defined price based on actual sales transactions published and maintained by Centers for Medicare & Medicaid Services (CMS) and used for physician administered, infused, and injected drugs.

Medicare Physician Fee Schedule (MPFS) - Document published and maintained by CMS that includes relative value units and other relevant information used in determining professional pricing.

Our health plan’s reimbursement uses several CMS Medicare Prospective Payment Systems (“PPS”) as well as Medicare fee schedules for claims pricing. This includes, but is not limited to, Inpatient Prospective Payment System (IPPS), Outpatient Prospective Payment System (OPPS), MPFS, CMS DMEPOS, Clinical Laboratory Fee Schedule (CLAB), and ASP pricing.
When current PPS and Medicare fee schedules are used, claims submitted during the time period after CMS updates the fee schedule, but before our health plan has implemented those changes from the vendor into our system, will be processed using the applicable fees prior to CMS’s update.

Example 1:

• Date of service on claim 11/01/2023.
• Claim completed processing in our system on 11/15/2023.
• CMS updated applicable fee with an effective date of 11/01/2023 but our health plan implemented in our system on 12/01/2023.

• Claim is adjudicated using the applicable fee in our system on 11/15/2023 (and not the CMS updated fee); an adjustment will not be made unless required by CMS.

Example 2:

• Date of service on claim 11/01/2023.
• CMS updated applicable fee with an effective date of 11/01/2023; our health plan implemented in our system on 12/01/2023.
• Claim completed processing in our system on 12/15/2023.

• Claim is adjudicated using the updated applicable fee in our system on 12/15/2023.

When a non-current Medicare-based fee schedule is used for a Medicare Advantage product, our health plan will generally use the CMS fee effective date as specified below:

a) New Codes
When a code is newly issued, our health plan will use the fee/Relative Value Unit (RVU) published by CMS prior to the new code’s implementation date. Any CMS changes made to the RVU or fee after the code is implemented will be administered using the “Existing Codes” instructions.

b) Existing Codes
Our health plan will use CMS effective dates for changes to existing codes except where provider contract language indicates otherwise.

Our health plan provides reimbursement for claims in accordance with the date of service of the claim and the applicable fee reflected in our system in effect at the time the claim is processed. Our health plan will update our claims payment system within sixty (60) days of the date on which our vendor releases updates with regards to CMS’s Medicare Prospective Payment System (PPS) and Medicare fee schedules. Claims will only be adjusted when mandatorily required by CMS.

Our health plan reserves the right to set a fee schedule amount for any code, whether that code has a published CMS fee.

None

Pricing Codes without RVUs

Drugs, Immunizations/Vaccines, Radiopharmaceuticals, and Skin Substitutes Reimbursed Under Medical Coverage