Starting Oct. 1, additional specialty medications require authorization for BCN AdvantageSM members
For dates of service on or after Oct. 1, 2018, additional specialty medications covered under the Medicare Part B medical benefit require authorization for BCN Advantage members.
We first communicated about this in the article Starting Oct. 1, additional specialty medications require authorization for BCN Advantage members, on page 28 of the July-August 2018 BCN Provider News.
Please review the article to see which drugs require authorization starting October 1.
Exception: Vivaglobin® (HCPCS code J1562) will not require authorization because it is being discontinued. This is a change from what we communicated in the newsletter article.
These medications are not self administered. They must be given by injection or infusion by a physician or health care professional in the office or outpatient facility setting.
These medications require authorization when billed as a professional service (via the paper HCFA 1500 claim form or electronically as an 837P transaction) or as an outpatient facility service (via the UB-04 or electronically as an 837I transaction) and one of the following place of service codes is used:
- Physician office (Place of Service code 11)
- Outpatient facility (Place of Service codes 19, 22 and 24)
Note: In the July-August 2018 newsletter article, we mentioned only Place of Service codes 19 and 22 for outpatient facilities, but authorization is also required for Place of Service code 24.
Please review the July-August newsletter article for additional information.
In addition, look for an article in the September-October 2018 BCN Provider News that will clarify these changes.
Posted: July 2018
Line of business: Blue Care Network