Change Request Detail
No.
1180
Date
10/1/2012
Submitter
Type of Request
Professional Claim (HCFA 1500)
Status
DSMO Process Completed
Business Reason
In order to remain competitive and to best service its members, it is imperative that payers be able to develop and implement comprehensive specialty pharmaceutical programs that are in accordance and compliance with the standard transaction rules. 

Over the last 5 years, specialty pharmacy has become one of the fastest growing areas in healthcare, with a growth rate of 15% - 20%. The medical-drug spend on specialty drugs is increasing 10% - 13%, which is 2-3 times faster than pharmacy drug costs.  Both cost and utilization trends are dramatically increasing for specialty drugs; 20% of specialty drug costs could comprise up to 50% of the total drug spend for some payers by 2015 if not managed appropriately.  Employer groups are requesting utilization and cost management of specialty drugs from payers.  Payers need to have programs in place to respond to these requests. 

Specialty/high cost drugs are currently not managed under the medical benefit due to situational rule limitations for commercial payers resulting in the inability to capture and price medical drug at the NDC level data and inconsistent pricing of Not Otherwise Classified Drug Codes (NOC)

The ability to address market trends by managing specialty drugs under the medical benefit will:

   Ensure the appropriateness and use of high-cost and disease-specific medications/drugs
   Allow commercial payers to follow the same rules and standards currently only available under federal and/or state mandated programs such as Medicare and Medicaid for industry standards of managing specialty drugs in the marketplace
   Address claims systems pricing and processing capabilities (reduce manual processing and duplicative efforts)
   Optimize the quality, consistency, cost and utilization management controls
   Optimize the use of specialty drugs in other distribution channels
   Provide membership and groups with accurate pricing and application of clinical criteria. 
   Manage the high costs associated with specialty pharmaceuticals and reduce exposure to uncontrolled costs.
   Capture the NDC level of information to enhance reporting and pricing to capitalize on discount rates.
   Provide clinical criteria to providers before treatment begins. 
   Allow for optimal rebate management and outcomes based contracting.
Suggestion

Suggestion
Request for changing Situational Rule in 005010X222 (Professional 837) TR3 for LIN segment.

Current Language:
Required when government regulation mandates that prescribed drugs and biologics are reported with NDC numbers. OR Required when the provider or submitter chooses to report NDC numbers to enhance the claim reporting or adjudication processes. If not required by this implementation guide, do not send.

Proposed Changed Language:
Required when government regulation mandates or commercial carrier requires that prescribed drugs and biologics are reported with NDC numbers. OR Required when the provider or submitter chooses to report NDC numbers to enhance the claim reporting or adjudication processes. If not required by this implementation guide, do not send.
DSMO Category
D
Recommendation
The DSMO was unable to come to a consensus on this request. If the submitter chooses to resubmit another change request, or provide more information on an appeal - more information about the business need should be provided, specifically to clarify if this request is for specialty drugs only versus all drugs, and if this is for prescribed medications or physician administered drugs.

Appeal Recommendation