Updated — Medicare Part B medical specialty drug authorization: Clarification regarding Prolia and XgevaThis message was updated to show that authorization requests for Xgeva should be submitted using the brand name and not the generic name of the drug.
Part B specialty drugs Prolia® and Xgeva® have the same generic name, denosumab, and HCPCS code, J0897. Both drugs require authorization for Medicare Plus BlueSM PPO and BCN AdvantageSM members.
However, the system through which you request authorization varies as follows:
Note: Be sure to use the brand name when requesting Xgeva through the AIM ProviderPortal so AIM will know you are ordering the correct medication. Using the generic name, denosumab, can cause delays in the prior authorization process.
How to bill
Be sure to enter the following National Drug Code numbers on the claim, along with the HCPCS code J0897, to ensure appropriate and timely reimbursement.
For Medicare Plus Blue and BCN Advantage, we require authorization for these medications for all outpatient sites of care when you bill the medications as a professional service or as an outpatient facility service and you bill as follows:
You can quickly submit authorization requests through the NovoLogix online tool and through AIM Specialty Health.
If you need to request access to Provider Secured Services, complete the Provider Secured Services Application form and fax it to the number on the form.
For information about registering for and accessing the AIM ProviderPortal, see the Frequently asked questions page on the AIM Specialty Health website*.
*Clicking this link means that you're leaving the Blue Cross Blue Shield of Michigan and Blue Care Network website. While we recommend this site, we're required to let you know we're not responsible for its content.
Posted: December 2019
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network