Change Request Detail
No.
1193
Date
4/10/2014
Submitter
Type of Request
Professional Claim (HCFA 1500)
Status
DSMO Process Completed
Business Reason
Request for changing Situational Rule in 005010X222 (Professional 837) TR3 for LIN segment. This request pertains to specialty drugs and specialty drug providers whose scope of practice allows them to provide/administer drugs that are billed to the medical benefit such as individiual practitioners (md, do, cnp, physician assistants), vaccine immunization pharmacies, home infusion therapy, ambulatory infusion center, specialty pharmacies, durable medical equipment, and hemophilia.
In order to remain competitive and to best service its members, it is imperative that commercial 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 commercial payers by 2015 if not managed appropriately.  Employer groups are requesting utilization and cost management of specialty drugs from commercial payers.  They 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
Revise the situational rule for Loop 2410, 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:
Situational Rule
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.
OR
Required when an HHS approved pilot project specifies reporting of Universal Product
Number (UPN) by parties registered in the pilot and their trading partners.
OR
Required when government regulation mandates that medical and surgical supplies are
reported with UPN’s
OR
Required when adjudication is impacted by the inclusion of specific NDC numbers for biological and specialty drugs.
If not required by this implementation guide, do not send
DSMO Category
D
Recommendation
Disapprove. The DSMO believes that the existing language of the situational rules allow for reporting of specialty drugs and biologics.
Appeal Recommendation