08/14/2023

Health Alliance Plan

Health Alliance Plan Managed Care Committee Member

April Danish, CHONC - Newland Medical Associates

New JZ Claims Modifier for Certain Medicare Part B Drugs
Clarification to communication posted on June 27

Please follow the Centers for Medicare & Medicaid Services guidelines for JZ modifier for HAP Medicare Advantage claims. See details below.

Per CMS, effective July 1, 2023:

• You must report the JZ modifier on all claims that bill for drugs separately payable under Part B when there’s no discarded amount from single-dose containers or single-use packages.
• For the amount you administer, the claim line should include:
  • The billing and payment code, such as a HCPCS code, describing the given drug;
  • The JZ modifier showing there were no discarded amounts, and
  • The number of units administered in the units’ field

The JZ modifier requirements apply to:

• All separately payable drugs with status indicators:
  • “G” (pass-through drugs and biologicals) or
  • “K” (non pass-through drugs and nonimplantable biologicals, including therapeutic radiopharmaceuticals) under the Outpatient Prospective Payment System (OPPS)
• All separately payable drugs assigned payment indicator “K2” (drugs and biologicals paid separately when provided integral to a surgical procedure on ASC list; payment based on OPPS rate) under the ASC payment system

There are no changes regarding the reporting of the JW modifier.

Reminder – Prior Authorization Requirement Lists Updated Monthly
Our prior authorization requirements lists are updated monthly. A summary of changes from the previous month is also available. To access these lists:

• Log in at hap.org
• Select Quick links
• Select Procedure Reference Lists and refer to the appropriate list

Remember, there are many services and procedures that do not require prior authorization and it only takes a minute to check! When you open a list, you can search for a code by pressing the “ctrl” key and the letter F at the same time and entering a code in the search box.

Reminder - Keep Provider Information Updated in NPPES
It’s important to ensure your data in the National Plan & Provider Enumeration System (NPPES) is accurate. The Centers for Medicare & Medicaid Services (CMS) is encouraging health plans to use NPPES as a resource for online provider directories. By using NPPES database for provider directories, we could decrease the frequency we contact you for this information.

To verify your information, log in at the NPPES website. When reviewing, pay close attention to:

• Provider name
• Mailing address
• Telephone and fax numbers
• Specialty
• Taxonomy

Be sure to remove any practice locations no longer in use and only include addresses where:

• You practice
• You actively see patients
• Patients can call and make an appointment

Be Sure To Update Your Online Profile If You Change Your Email Address
If you change your email address, it’s important to update your online profile. If we don’t have your correct email address in our system, then:

• You can’t use forgot my username/password functionality.
• It will be harder to contact you for important and time-sensitive information.

Updating your online profile is easy! All you have to do is:

1. Log in at hap.org
2. Select Update Profile
3. Select Edit
4. Enter your correct, unique email address (please do not use a generic office email address)
5. Select Save

Front End Claims Rejected in Error in July
Recently, we learned claims submitted during July 2023 were receiving front end rejections with the following error:

1085: NPI and Entity type qualifier combination does not align in NPPES or is not active in NPPES

The error was due to the July National Plan and Provider Enumeration System (NPPES) file missing NPI records. We’ve downloaded a new file and this issue has been corrected.

If you received the above error for claims submitted during July 2023, please resubmit these claims to HAP or HAP Empowered for processing.