National Government Services Gap-fill Pricing Requests 2021

NGS, the MAC for Jurisdictions 6 and K has received the new laboratory test codes identified by CMS that require gap-fill pricing for 2021.

The Protecting Access to Medicare Act (PAMA) regulations instruct the MACs to establish local payment amounts for the new laboratory test codes using the following sources of information, if available:

• • Charges for the test and routine discounts to charges
  • Resources required to perform the test
  • Payment amounts determined by other payors
  • Charges, payment amounts, and resources required for other tests that may be comparable or otherwise relevant

Process

NGS will send individual letters which are proprietary code-specific to laboratories requesting the information listed above which must be returned by 3/19/2021.

Also, NGS requests information from laboratories regarding the establishment of pricing under the Medicare program for the following laboratory test codes: 86328, 86769, 87635, U0001, U0002, U0003, and U0004.

Responses

Please note that your information will be kept to the greatest degree of confidentiality and will not be disclosed, except as may be necessary to share with others under confidentiality agreements with CMS for the sole purpose of establishing Medicare clinical laboratory fee schedule gap- fill pricing.

Your responses will be reviewed and evaluated by NGS and if proper, set forth in its recommendations to CMS of the appropriate fees for these tests. If no response is received, the fee will be determined by evaluating the charges, payment amounts, and resources required for other tests that may be comparable or otherwise relevant.

NGS kindly requests responses be submitted to ngscmd@anthem.com by 3/19/2021.

Posted 2/12/2021