Home Administrative Billing & Reimbursement BlueCard® Health and Wellness Medical PEAR portal Pharmacy Products Quality Management

Proper processing of claims regarding CAR T-cell therapy for Medicare Advantage members

December 11, 2019

The Centers for Medicare & Medicaid Services (CMS) have finalized a national coverage policy for chimeric antigen receptor (CAR) T-cell therapies Kymriah™ and Yescarta™. As of January 1, 2019, coverage and reimbursement for CAR T-cell therapy for Independence Medicare Advantage members is processed through the local Medicare Administrative Contractor (MAC) for calendar years 2019 and 2020.

Background

CMS identified CAR T-cell therapy as meeting the significant cost threshold. When CMS identifies a service has met this threshold, the Medicare Advantage plan is not responsible for the processing of claims or the provision of traditional medical management for the service, during the specified time period. In order for claims to be processed correctly, providers must submit all claims for CAR T-cell therapy and associated costs to the local MAC.

Claims submission

Claims for CAR T-cell therapy should not be submitted to the Medicare Advantage plan. If claims are not submitted properly, providers will receive a message to submit these services to the appropriate Medicare fiscal intermediary or carrier for coverage and payment determination.

 

Policy updates

Independence Medicare Advantage policy #MA08.093e: Chimeric Antigen Receptor (CAR) Therapy was reviewed to determine if any changes were required based on the CMS policy.

The following changes were made:

  • This policy has been updated to communicate coverage and reimbursement for CAR-T Cell therapy for Independence Medicare Advantage members will be processed through the local MAC, as this therapy has been identified as meeting Medicare's the significant cost threshold.
  • The following CPT codes havebeen added to this policy:
    • 0537T, 0538T, 0539T, 0540T
  • All ICD-10 CM codes have been deleted from Attachment A of this policy.

Learn more

To view this policy, visit our Medical Policy Portal.

CPT Copyright 2017 American Medical Association. All Rights Reserved. CPT® is a registered trademark of the American Medical Association.


This content was prepared for the Provider News Center and may not be reproduced in any way without the express written permission of Independence Blue Cross. Independence Blue Cross is an independent licensee of the Blue Cross and Blue Shield Association.
Connect with us     Facebook     Twitter     Flickr     YouTube     Walk the Talk    Independence Pinterest    Independence LinkedIn    Independence Instagram Site Map        Anti-Fraud        Privacy Policy        Legal        Disclaimer
© 2023 Independence Blue Cross.
Independence Blue Cross is an independent licensee of the Blue Cross and Blue Shield Association, serving the health insurance needs of Philadelphia and southeastern Pennsylvania.