Infusion Therapy Guidelines for Non-Home Infusion, Specialty Infusion & Specialty Pharmacy Providers
Provider Administrative Policy
Our provider administrative policies contain information regarding claims submission, reimbursement, and other information in order to achieve an efficient relationship with our providers. These policies are not an authorization or explanation of benefits. Blue Cross of Idaho retains the right to add to, delete from and otherwise modify this policy in accordance with our provider contracts
Infusion therapy services require prior authorization (see prior authorization drug list) regardless of place of service or provider of service. When billing for infusion therapy, please submit claims with the following information populated. Blue Cross of Idaho can only apply correct benefits to prior authorized services submitted in this manner.
- Diagnosis code(s)
- Current acceptable CPT and/or HCPCS coding
- You must bill services with "from and through" dates for the total episode of care or a maximum of a 7 day span.. This applies to nursing services, therapy drugs, per diems, ancillary charges and any additional services that a provider would bill for infusion therapy.
- You must bill all services related to infusion therapy service on the same claim form.
- Units billed must represent the nursing services, therapy drugs and any additional services provided during that week billed.
- National Drug codes (NDC) are required for all J codes.
- We require a description, along with the NDC for J codes that do not provide an exact description of the drug. Please refer to PAP227 for additional information on unlisted and unclassified codes.
Providers who administer infusion therapy to patients must also:
- Provide 24-hour coverage for infusion therapy patients.
- Ensure that a physician skilled in infusion therapy supervises infusions provided in an office setting.
- Assume care from the point of hospital discharge to include weekends. We do not allow temporary referrals.
- To maintain continuity of member care; if a member receiving infusion therapy is admitted to a hospital, upon discharge, infusion therapy services will resume with the same infusion therapy provider. You cannot redirect services to another provider type.
- You must refer members who require nursing for home infusion services to a contracting Home IV therapy company for complete treatment.
Please bill all services provided for a total episode of care or a maximum of 7 days and associated charges on the same claim.
Codes should be specific for the type of service provided. If a code is invalid, we will return the claim to the provider for proper coding.
All claims with a J3490 or J3590 code are subject to review and we may return them to the provider for more appropriate coding. Provide an NDC and narrative description of the drug on claims. Refer to PAP227.
We established per diem rates in your fee schedules. When billed, the code must be the most appropriate and specific CPT for the services provided. The following services are included in the Per Diem allowance and are not separately billable:
- Administrative services
- Ancillary medical supplies (syringes, tubing, space balls, elastomeric devices, etc.)
- Clinical pharmacy service and kinetic dosing services
- Coordination of care with hospital, physician and patient/caregiver
- Equipment rental (pump and pole)
- A hospital nursing assessment visit on behalf of Blue Cross of Idaho to evaluate patients for home infusion care
- Intravenous solutions (Diluent, Solution, Heparin, Saline, Steril Water, etc.)
- Medication and supply delivery
- Nutritional assessment
- Professional pharmacy services and compounding fees
Factor: Submit claims for factor products with the "from and through" date as a one-day date span, which is the date of shipment to the member.
If a provider cannot provide nursing services, the provider must refer all services, including infusion and nursing to a contracting Home IV therapy provider. Blue Cross of Idaho does not accept individual home healthcare claims during an infusion therapy per diem authorization. All services related to infusion therapy require prior authorization and review. Providers are prohibited from billing for non face-to-face services such as travel time, care coordination, or time spent completing documentation. All skilled services billed must be for direct face-to-face time with member.
We may perform post payment audits to monitor emergency room and home health visits associated with infusion therapy episodes of care.
|September 2012||Revised||Updated billing requirements.|