Changes to Amount in Controversy (AIC) for Appeals in 2019

  • Jan 8, 2019

The claims value in dispute must meet the threshold for obtaining an Administrative Law Judge (ALJ) hearing and a judicial review in Federal District Court. This is called the “amount in controversy.” The amount in controversy is recalculated and published on an annual basis, and is identified in your appeal notice of decision. The AIC for appeals filed on or after January 1, 2019: ALJ hearing...

Read


MolDX Local Coverage Determination (LCD) Updates

  • Jan 8, 2019

The MolDX: HLA-B*15:02 Genetic Testing L36033 A/B MAC LCD was revised. Revision Effective Date For services performed on or after 12/06/2018 Added B20 in the ICD-10 Group 1 List as a covered code. The addition of B20 is retro-effective to 2/26/18.

Read


AHA, AAMC Sue Trump Administration Over Site-neutral Payment Rule

  • Jan 8, 2019

Last month, the Centers for Medicare & Medicaid Services (CMS) finalized the 2019 Outpatient Prospective Payment System (OPPS) rule (PDF), which will gradually institute site-neutral payments in the Medicare program over the next two years. In a complaint filed in the U.S. District Court for the District of Columbia, the American Hospital Association (AHA) and the Association of...

Read


Legislators Release New Draft Bill Incorporating FDA Ideas for Diagnostics Regulation

  • Jan 8, 2019

The FDA's version of the bill includes proposals related to premarket approval, provisional approval, and a precertification program, and makes explicit its authority to revoke approval, request raw data, and take corrective action against test developers in order to protect the public health. Anticipating the release of the VALID Act, FDA Commissioner Scott Gottlieb last week issued a definitive...

Read


Medicare Program: Clinical Laboratory Improvement Amendments (CLIA) of 1988 Fees (CMS-3356-NC)

  • Jan 8, 2019

The fact sheet discusses why CMS is increasing the CLIA fees for the first time in 20 years.  Based on the agency’s financial data review, they project that a 20 percent fee increase will sustain and maintain the CLIA program through FY 2021.  CMS is required to update the program’s fee schedule because current fees are no longer sufficient to cover costs of the CLIA program. This user...

Read


Non-Participating Family PACT Providers

  • Jan 8, 2019

Effective January 1, 2019, the Family Planning, Access, Care and Treatment (Family PACT) Program is deactivating providers who have not submitted a claim for Family PACT services for one year. Pursuant to Welfare and Institutions Code (W&I Code), Section 24005(i)(3): The department shall deactivate, immediately and without prior notice, (…) when a provider has not submitted a claim for...

Read


Calendar Year (CY) 2019 Annual Update for Clinical Laboratory Fee Schedule and Laboratory Services Subject to Reasonable Charge Payment

  • Jan 8, 2019

CR 11076 provides instructions for the Calendar Year (CY) 2019 Clinical Laboratory Fee Schedule (CLFS), mapping for new codes for clinical laboratory tests, and updates for laboratory costs subject to the reasonable charge payment. Next CLFS Data Collection Period Revisions to the Definition of Applicable Laboratory Coding for Health Common Procedure Coding System (HCPCS) Panel Codes Update...

Read


Next Generation Sequencing NCD MLN Matters Article — New

  • Jan 8, 2019

National Coverage Determination (NCD90.2): Next Generation Sequencing (NGS) I. SUMMARY OF CHANGES: The purpose of this Change Request (CR) is to inform contractors that effective March 16, 2018, the Centers for Medicare & Medicaid Services covers diagnostic laboratory tests using next generation sequencing when performed in a Clinical Laboratory Improvement Amendments- certified laboratory...

Read