Prerequisites for both: Prior Authorization Required
Submit all bills for home infusion on a CMS 1500 form, or its electronic equivalent.
Enter the authorization number in Form Locator 23 on CMS 1500, or its electronic equivalent.
When more than one date of service is submitted per claim form, itemize each date of service on a separate claim line in Form Locator 45.
For each drug, enteral, or parenteral product, submit the appropriate HCPCS code in addition to the:
-NDC number in 11-digit format
-Frequency of administration
-Duration of infusion (if applicable).
For drugs, enter the drug units implicit in the NDC number (e.g. number of vials).
Please Note: Use of only HCPCS “J” codes for drugs will deny for missing NDC number.
For enteral nutrition formulae, enter the number of cans in the units field.
Please Note: Do not enter number of cases or the Red Book value listed in milligrams (ml) in the units’ field. Use of only HCPCS “B” codes for enteral/parenteral formulae, will deny for missing NDC number.
Per Diem rates do not apply to nutritional formulae taken orally. Reimbursement will be for the formulae, only.
When home nursing services are required for home infusion and specialty drug administration, bill using CPT 99601 for each nursing visit lasting up to two hours, in addition to CPT 99602 for nursing visits lasting more than two hours, with the applicable number of unit(s) for each additional hour.
When a member receives two or more concurrently administered therapies, append one of the modifier(s) listed below:
Modifier -SH : Second concurrently administered infusion therapy
Modifier -SJ : Third or more concurrently administered infusion therapy