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Information for Physicians

Training for 2008 Participating CAP Physicians During the 2009 CAP Postponement

Noridian Administrative Services, the designated carrier for the CAP, offers interactive, online workshops about the CAP for Part B Drugs and Biologicals. During the 2009 CAP postponement, a limited number of workshops are being held to assist 2008 CAP physicians with transitioning out of the CAP. Specific topics will include billing for CAP claims and reconciling CAP drug inventory. NAS staff will be available to answer questions during the session. Interested parties may view additional information about and register for these workshops at the 'Register for CAP Physician Workshops' link in the "Related Links Outside CMS" section below. The next workshops will be held on the following dates:

  • 01/29/09 at 2:00 pm CST
  • 02/12/09 at 2:00 pm CST

CAP Claims Submission Deadlines and Unused CAP Drugs

In preparation for the 2009 CAP postponement, the following is a reminder about upcoming CAP deadlines.  It is very important that participating CAP physicians understand and comply with these deadlines because failure to do so will affect physicians' ability to be reimbursed.

CAP Drugs Administered during 2008

  • All CAP drug claims must have a date of service on or before December 31, 2008, and physicians' corresponding CAP drug administration claims must be submitted on or before January 30, 2009. 
  • CAP drug claims for dates of service after December 31, 2008 will be denied.  
  • CAP drugs that have not been administered by December 31, 2008 are the property of the Approved CAP Vendor.

CAP Drugs NOT Administered by December 31, 2008

  • CAP physicians must return any unused CAP drugs to the Approved CAP Vendor by February 28, 2009. 
  • CAP drugs are the property of the Approved CAP Vendor. Therefore, physicians who have not returned these drugs to the Approved CAP vendor on or before February 28, 2009 will be liable for the cost of drugs.   
  • Please note that CAP physicians may contact the Approved CAP Vendor to discuss the option of purchasing unused CAP drugs. 

Emergency Restocking of CAP Drugs for Dates of Services on or before December 31, 2008

  • When permitted under the emergency restocking provisions, physicians may submit a prescription order for a CAP drug to replace what they used from their own stock (the emergency restocking provision). Physicians may request replacement drugs ONLY if the date of service is on or before December 31, 2008, AND the corresponding drug administration claim has been submitted on or before January 30, 2009.
  • Physicians must request replacement drugs by January 30, 2009.
  • The Approved CAP Vendor will not send replacement products under the CAP emergency restocking provision (J2 modifier claims) after February 28, 2009. 
  • CAP physicians who have not submitted a prescription order and a request for replacement drugs under the emergency restocking provision as described above will not be able to bill Medicare under the ASP system for the CAP drugs that they administered on or before December 31, 2008 from their private stock. 

What should you do to prepare?

Physicians who are participating in the CAP during 2008 are encouraged to contact the Approved CAP Vendor and reconcile their inventories as soon as possible.  Contact information for the Approved CAP Vendor, BioScrip, is available on their website, which can be accessed via the 'Related Links Outside CMS' section below, or on the CAP "Approved CAP Vendor" page (see link in the menu to the left). 

September 18, 2008 Ask the Contractor  Teleconference (ACT)Transcript and PowerPoint Presentation

On September 18, 2008, CMS hosted an ACT for CAP physicians to discuss the postponement of the CAP for 2009 and to assist participating CAP physicians in planning for the transition out of the program.  The ATC was moderated by Noridian Administrative Services (NAS), the CAP Designated Carrier.  The transcript for this teleconference is available in the 'Training and Events' section on the NAS website.  The NAS website can be accessed via the 'Related Links Outside CMS' section below.

2008 Quarterly CAP Drug Lists

The 2008 quarterly CAP drug lists have been moved to the 'Approved CAP Vendor' page (see link to the left).

Post Payment Review and Medical Record Requests for 2009

After January 1, 2009, the CAP post-payment review process will continue for 2008 claims.  The post-payment review process for the CAP is conducted to verify drug administration for Medicare claims submitted by an Approved CAP Vendor. For this process, a small sample of physician and Vendor claims and other documentation is examined in order to establish that drugs billed by an Approved CAP Vendor were administered and were medically necessary.

To support this review, participating CAP physicians may receive a request for copies of medical records from the CAP designated carrier, Noridian Administrative Services (NAS).  Medicare requirements require participating CAP physicians to submit all information necessary to support the services billed on claims.

Participating CAP physicians must submit medical records to NAS within the requested timeframe.  This submission should include the patient's drug administration record and all other records supporting medical necessity for the drug.  If CAP post payment review activity cannot establish that a drug was administered, then the vendor's drug claim will be denied. The associated physician drug administration claim will also be referred to the physician's local carrier for review and recoupment as necessary.

For additional information on the post payment review process, please visit NAS's website via the 'Related Links Outside CMS' section below.

Feedback about the CAP: A Special Open Door Forum (ODF) Teleconference on the 2009 CAP Postponement and How to Submit E-mail Comments

The Centers for Medicare & Medicaid Services (CMS) is soliciting public feedback about the CAP. CMS is interested in hearing about a range of issues, including, but not limited to:

  • the categories of drugs provided under the CAP
  • the distribution of areas that are served by the CAP
  • procedural changes that may increase the program's flexibility and appeal to potential vendors and physicians.

On December 3, 2008, CMS will host a Special ODF Teleconference to obtain feedback about the program. This teleconference will be a listening session and is intended for current and former participating CAP physicians, potential Approved CAP Vendors, and any other interested parties. CMS will assess the information that it receives as it considers implementing changes to the CAP.

Call Details:

Date and Time: December 3, 2008 from 2:00-3:30PM EST
Toll Free Call Number: (800) 837-1935
Conference ID: 66307647

Interested parties can also submit comments to the CAP e-mailbox at MMA303DDrugBid@cms.hhs.gov

September 18, 2008 Ask the Contractor Teleconference (ACT) PowerPoint Presentation

On September 18, 2008, CMS hosted an ACT for CAP physicians to discuss the postponement of the CAP for 2009 and to assist participating CAP physicians in planning for the transition out of the program. The ACT was moderated by Noridian Administrative Services (NAS), the CAP Designated Carrier. The transcript for this teleconference is available in the 'Training and Events' section on the NAS website. The NAS website can be accessed via the 'Related Links Outside CMS' section below.

The PowerPoint slide presentation for the ACT is available in the 'Training and Events' section on the NAS website. The NAS website can be accessed via the 'Related Links Outside CMS' section below.

2009 CAP Postponement Article

A Medicare Learning Network (MLN) Matters Special Edition article on the 2009 CAP postponement is now available on the CMS website.  This article contains billing, drug ordering, claims processing, and other information for Participating CAP Physicians on the transition from CAP to the ASP "buy and bill" methodology for 2009.  A link to this article is available in the 'Related Links Inside CMS' section below.

2009 CAP Postponement

On September 10, 2008, the Centers for Medicare & Medicaid Services (CMS) announced the postponement of the 2009 Medicare Part B Competitive Acquisition Program (CAP).  The program will continue through December 31, 2008.

Earlier this year, CMS accepted bids for vendor contracts for the 2009-11 CAP.  While CMS received several qualified bids, contractual issues with the successful bidders resulted in CMS postponing the 2009 program.  As a result, CAP physician election for participation in the CAP in 2009 will not be held, and CAP drugs will not be available from an approved CAP vendor for dates of service after December 31, 2008.  

Later this fall, CMS will provide additional guidance for participating CAP physicians on how to transition out of the program. This information will be posted on the CMS CAP Physician's page.

CMS also plans to seek feedback on the CAP from participating physicians, potential vendors, and other interested parties. CMS will assess the information and consider implementing changes to the CAP before proceeding with another bid solicitation.  As part of the process, CMS is interested in hearing from the public about a range of issues, including, but not limited to, the categories of drugs provided under the CAP, the distribution of areas that are served by the CAP, and procedural changes that may increase the program's flexibility and appeal to potential vendors and physicians.

Information about how to submit comments will be available on this website. 

CAP Physician "Ask-the-Contractor" Teleconference for Providers on September 18, 2008 – Phone Number Change

The Centers for Medicare & Medicaid Services (CMS) will host an "Ask-the-Contractor" teleconference on September 18, 2008 to discuss the postponement of the CAP for 2009 and to assist participating CAP physicians in planning for the transition out of the program.  The call will be conducted by the CAP designated carrier, Noridian Administrative Services (NAS).  NAS staff will be available to respond to inquiries during a question and answer session after the presentation.  This call is intended for all interested providers and their staff.

Call Details:

Title: Competitive Acquisition Program (CAP) for Part B Drugs and Biologicals – Transitioning Physicians out of CAP
Date and Time: September 18, 2008 at 2:00PM CST
Domestic U.S. Call Number: (800) 398-9397
U.S. Territories Call Number: (612) 332-0226

A PowerPoint slide presentation to accompany the "Ask-the-Contractor" teleconference will be posted on the NAS website at least one day prior to the teleconference.  The NAS website can be accessed via the 'Related Links Outside CMS' section below.

CAP Physician Billing Tips" Handout for Submitting CAP Claims

An updated version of the "CAP Physician Billing Tips" handout is now available.  This reference contains information on the claims submission requirements for the CAP such as the CAP modifiers and other necessary elements. A copy of this document is available in the 'Downloads' section below. 

New Changes to the CAP

The Centers for Medicare and Medicaid Services (CMS) published the 2008 Physician Fee Schedule (PFS) Final Rule in the Federal Register on November 27, 2007, which included regulations on the CAP that are effective January 1, 2008. Changes to the CAP due to new or updated regulations include:
- CAP drug administration claims may now be filed within 30 days of administering CAP drugs
- Participating CAP Physicians may now request to leave the CAP within the first 60 days of election if program participation results in any burden to a practice (ex: difficulty meeting CAP drug ordering or billing requirements)
- After 60 days, a Participating CAP Physician may request to leave the CAP if an unexpected change in circumstance results in CAP participation becoming a burden to a practice (ex: a change in patient population or practice personnel)

A copy of the 2008 PFS Final Rule can be obtained in the "Downloads" section of the "Regulations and Notices" page on this website.

Beneficiary Fact Sheet

Participating CAP Physicians are required to provide this fact sheet during a Medicare beneficiary's first visit to the physician's office subsequent to the start of a physician¡¦s participation in the CAP.  When distributing the CAP Beneficiary Fact Sheet, physicians may include additional information, such as contact information for the Approved CAP Vendor.  Participating CAP Physicians are only required to distribute the Beneficiary Fact Sheet once to each beneficiary but may provide the beneficiary with additional copies as necessary.

The Beneficiary Fact Sheet is available in both English and Spanish.  Use the following directions to order this document in English, publication #11148.  Up to 100 copies of the fact sheet may be ordered at a time.  If you have any problems ordering this document, send an email to mailpubs@cms.hhs.gov.

  1. Click on the CMS Publications Mailing List link below.  (See the "Related Links Inside CMS)
  2. Select the link "New user" Register here.
  3. Enter the password all lowercase: cms07
  4. Create a username and enter it twice.
  5. You will be prompted to change your password. The password can have numbers and/or letters. It must be at least five characters long.
  6. When filling in your contact information choose the following category from the drop down menu: Physicians.
  7. Proceed to fill in all forms required to register. If you do not add a shipping address after adding the contact information you will not see the publications. 
  8. Please note we do not ship publications to PO Boxes. Please refrain from including them in your address.

Both the English and Spanish versions are available on the CAP website in the "Downloads" section below.

Key Points about the CAP

  • Participation in the CAP is voluntary.
  • Physicians who are new to Medicare will have 90 days to elect to participate in the CAP.
  • For 2007 and subsequent years, the CAP program will run from January 1 to December 31 with a 45-day physician election period occurring in the fall.
  •  Drug administration claims will continue to be paid by the physician's local carrier.
  • All Local Coverage Determinations (LCDs) will continue to apply to CAP drug administration and CAP drug claims.
  • The drug CAP is separate from the Medicare Prescription Drug Benefit (Part D) that went into effect January 1, 2006.
  • The CAP for Part B Drugs and Biologicals is only for injectable and infused drugs currently billed under Part B that are administered in a physician's office, "incident to" a physician's service.
  • There is only one competitive acquisition geographic area for 2008, which includes all 50 states and territories.
  • There is one Approved CAP Vendor for 2008.
  • Once a physician has elected to participate in CAP, they must obtain all drugs on the CAP drug list from their chosen drug vendor.
  • Physicians still continue to purchase and bill Medicare under the Average Sale Price (ASP) system for those drugs that are not provided by the physician's Approved CAP Vendor. 
  • Physicians will acquire CAP drugs from the Approved CAP Vendor. The Approved CAP Vendor will be responsible for submitting a claim for the drug to the Designated CAP Carrier, Noridian Administrative Services (NAS.) 
  • The Approved CAP Vendor will be responsible for collecting the deductible and co-insurance from the beneficiary. This may not be collected until the Approved CAP Vendor has received Medicare payment for the drug (unless the CAP vendor has verified administration with the participating CAP).  Also, if the beneficiary has a supplemental insurance policy, the Approved CAP Vendor must wait to bill the beneficiary until payment from the supplementary insurer has been received.
  • Completed and signed Physician Election Agreement forms should be returned by mail to your local carrier. Medicare carriers' mailing addresses are available in the Downloads section below; use the address listed under "Carrier." DO NOT MAIL COMPLETED FORMS TO CMS HEADQUARTERS IN BALTIMORE, MD.