COMMON BILLING FAQs
Updated as of October 5, 2007
Here are a few frequently asked questions and answers regarding XELODA Reimbursement.
Frequently Asked Questions for Reimbursement
MEDICARE
1. Q: Is XELODA eligible for coverage under Medicare Part B or Part D?
A: XELODA has been eligible for Medicare Part B coverage for approved oncology indications since January 1, 1999 when prodrugs were added to the Oral Anti-Cancer Drug Local Medical Review Policy (now LCDs) (Source: Program Memorandum Intermediaries/Carriers; Transmittal No. AB-98-64; November 1998.)
CMS has further advised:
"To the extent that a Part B-covered oral anti-cancer drug has no other medically accepted indication besides cancer treatment, Part D plans should not include these drugs on their formularies because of Part B coverage.1"
Additional information about Part B and Part D drug coverage is available through the Centers for Medicare and Medicaid Services at the links below:
Medicare Parts B/D Coverage Issues
Medicare Parts B & D Further Information
2. Q: Have Medicare Part B DMEMAC contractors issued coverage policies for XELODA?
A: XELODA is included under the Oral Anti-Cancer Local Coverage Determinations (LCD) issued by Medicare. The LCDs and related policy article for each of the four Durable Medical Equipment Medicare Administrative Contractors (DMEMACs) that process Part B oral anti-cancer drug claims may be accessed at the links below.
Jurisdiction A - National Heritage Insurance Company
Jurisdiction B - National Government Services (NGS) formerly Administar
Jurisdiction C - Cigna Government Services
Jurisdiction D - Noridian Administrative Services
3. Q: What billing codes does CMS/Medicare require suppliers to use when billing Medicare Part B DMEMACs for XELODA?
A: Under most circumstances, CMS/Medicare requires suppliers to use 11-digit National Drugs Codes (NDCs) when billing Medicare DMEMACs for XELODA and the other oral anti-cancer drugs covered under the Oral Anti-Cancer Drug LCD. See LCDs and related policy article for additional information.
A list of NDCs eligible for coverage under the Oral Anti-Cancer LCDs may be obtained through the Pricing, Data Analysis and Coding (PDAC) website.
4. Q: Are there circumstances where Medicare directs providers to bill DMEMACs for XELODA with HCPCS codes, as opposed to NDCs?
A: Under most circumstances, the Oral Anti-Cancer Drug LCDs and related policy articles direct Medicare suppliers to use NDCs when billing for XELODA.
However, per CMS Transmittal 588 and MLN Matters Number MM3742, Medicare has directed DMEMACs to accept certain XELODA Clinical Trial Claims (subject to Section 110.17 - Anti-cancer Chemotherapy for Colorectal Cancer of the National Coverage Determinations Manual) with HCPCS codes J8520 (capecitabine, oral, 150 mg) and J8521 (capecitabine, oral, 500 mg) when accompanied by the “QR” modifier to show use in a clinical trial.
5. Q: Does CMS require a 10-digit or 11-digit NDC when billing Medicare Part B DMEMACs for XELODA?
A: CMS and Medicare requires 11-digits (5-4-2) NDCs when billing Medicare Part B DMEMACs for XELODA. Additional information is available through the ANSI ASC X12N 4010A1 837 Supplemental Guide or by contacting Medicare.
6. Q: What is the National Supplier Clearinghouse and what role does it play in Medicare?
A: The National Supplier Clearinghouse (NSC) is the national entity contracted by the Centers for Medicare & Medicaid Services (CMS) that issues Medicare Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) supplier authorization numbers. The NSC provides DMEPOS supplier applications, verifies application information, and administers file activity. The NSC also maintains a central data repository for information concerning DMEPOS suppliers, periodically re-enrolls active suppliers and uses the data to assist with fraud and abuse research.
Medicare suppliers need an DMEPOS supplier number to submit claims to DMEMACs. The NSC may be reached by calling 1-866-238-9652.
7. Q: How does Medicare DMEMACs reimburse Medicare suppliers for XELODA?
Physician Office/Pharmacy Suppliers
Medicare DMEMAC reimbursement for XELODA is based on 106% of the Average Sales Price (ASP). Medicare Part B drug reimbursement allowances are adjusted quarterly and posted on the CMS website.
For covered claims, Medicare will reimburse participating providers at 80% of the reimbursement allowable. Patients or their secondary insurers are responsible for paying the remaining 20%.
8. Q: What services are available through the Roche Oncoline Reimbursement Hotline?
A: The reimbursement hotline offers the most up-to-date information on coding, coverage, payment.
You can answers for and help with:
Coding, billing, coverage information specific to your geographic location and site of service
Support for filing claims, reviewing claim denials, and process guidance for appeals
Published reimbursement guidelines and criteria
Patience insurance verification for Medicare, Medicaid & commercial payors
9. Q: What are the eligibility requirements for the Patience Assistance Program (PAP)?
A: To be eligible for the Roche PAP program, a patient has to meet all the criteria listed below:
Legal resident of the United States, Puerto Rico, Guam and the U.S. Virgin Islands
Have an annual gross household income at or below 300% of the Federal Poverty Level (FPL)
Be under the care of an outpatient licensed healthcare provider
Complete a PAP application, and have it signed by both a licensed healthcare provider and the applicant. Patient's private insurance coverage will also be considered as part of the qualification process.
10. Q: How many days of therapy may be dispensed at one time to a Medicare beneficiary under the Oral Anti-Cancer Drug LCD?
A: According to the Oral Anti-Cancer Drug LCD, “the quantity of oral anticancer drugs that is dispensed should be limited to a 30-day supply. Prescriptions may be refillable.”
11. Q: How can I find a Medicare participating pharmacy?
A: You may call your regional DMEMAC to obtain a list of Medicare participating Pharmacies in your area.
Private Payors and Other Payors
12. Q: Is XELODA eligible for coverage under private health insurance and other payors/insurance?
A: Coverage, coding, and payment for XELODA and other drugs varies considerably by payor, plans, and patient-specific situations. Patients and providers should verify patient-specific benefits to determine applicable coverage, coding, and payment for each patient.
