AmeriHealth has adopted new claims reporting requirements for drugs obtained
from in-network home infusion vendors. The following information is required
when submitting drug claims for home infusion vendors that are not owned by a
hospital or health system in the AmeriHealth provider network:
- NDC. Report the specific National Drug Code (NDC) that corresponds
to the drug formulation administered to the member.
- HCPCS or CPT® codes. Report the specific Healthcare
Common Procedure Coding System (HCPCS) or Current Procedural Terminology (CPT)
code for the drug. Exception: For drugs without a specific HCPCS/CPT
code, report the J3490 or J3590 not otherwise classified (NOC) code, as
appropriate.
- Units of drug administered.Report drug units in multiples of the
dosage unit specified in the HCPCS/CPT code narrative. Exception: For
drugs without a specific HCPCS/CPT code, report the units in multiples of the
drug units specified in the NDC.
Failure to include these components in a claim may result in delayed
processing and reimbursement.
Note: The submission process for precertification requests through
the NaviNet® web portal has not changed.
For more information
Effective March 1, 2016, the following claim payment
policies have been updated to address these new billing requirements and
provide specific claims examples:
- Commercial: #00.01.49b: Reporting Requirements for Drugs and
Biologics
- Medicare Advantage: #MA00.024a: Reporting Requirements for Drugs and
Biologics
View these policies by visiting our Medical Policy Portal. Select Accept and Go to Medical
Policy Online, and then select the Commercial or Medicare
Advantage tab from the top of the page, depending on the version of the
policy you?d like to view. Then type the policy name or number in the Search
field.
Please note that this change only applies to home infusion vendors that are
not owned by hospitals or health systems in the AmeriHealth provider
network. Home infusion vendors owned by hospitals or health systems in the
AmeriHealth provider network should continue to bill according to the terms of
their Provider Agreement.
NaviNet is a registered trademark of NaviNet, Inc.
CPT copyright 2014 American Medical Association. All
rights reserved. CPT is a registered trademark of the American Medical
Association.