BENEFIT VERIFICATION and REIMBURSEMENT for LONG ACTING INJECTABLE ANTIPSYCHOTICS Benefit Verification Checklist When calling a payer to verify benefits, the following key questions should be considered: Benefit Verification Questions Is the LAI covered as a medical or pharmacy benefit or both? Are there any special distribution requirements? Does the patient have other insurance benefits that will need to be coordinated? Is prior authorization required? What is the prior authorization process? What is the phone number or fax number for the authorization department? How long will it take? What information is required? Patient Cost Questions What is the patient s deductible? Has the deductible been met? If not what amount has been applied to date? What is the patient s co-payment or co-insurance for the drug? Does the patient have an out-of-pocket maximum? Has the out of pocket maximum been met? If not, what amount has been applied to date? Does the patient have an annual or lifetime benefit maximum? Has the benefit maximum been met? If not, what amount has been applied to date? Reimbursement Questions What are the coding and claim submission requirements? What is the reimbursement amount for the LAI in question based on the patient s plan? What is the reimbursement amount for the administration procedure?
What is the process for submitting for reimbursement? Suggestions for Monitoring Benefit Changes Keep a spreadsheet of patients receiving LAIs to include: specific medication insurance company whether coverage is a pharmacy or medical benefit contact number coverage determination duration of coverage/when next authorization is required Ask patients at every injection visit whether their insurance has changed. Reimbursement Forms Forms used for reimbursement for LAIs for Medicare beneficiaries are also used by some Medicaid programs and some private insurances. Private payers can provide information about their specific submissions forms and processes. Claim Form CMS-1500 Used for services provided to Medicare beneficiaries in a physician s office. Claim Form CMS-1450 (UB-04) Used for services provided in hospitals, skilled nursing facilities, hospice, and other institutions. Coding Specific to LAI Reimbursement Healthcare Common Procedure Coding System (HCPCS) A set of health care procedure codes based on the American Medical Association s Current Procedural Terminology (CPT). Medicare requires their use to report physicianadministered drugs. The type of code will depend on the site of service. Drugs administered by injection will have a 5-digit code starting with J.
National Drug Code (NDC) Usually reserved for billing by pharmacies, but some private payers and the majority of Medicaid fee-for service programs require NDC for billing FDA uses a 10-digit code (5-3-2 format), payers often require an 11-digit code (5-4-2) format for claims and billing. Current Procedural Terminology (CPT) 96372, Therapeutic, prophylactic, or diagnostic injection; subcutaneous or intramuscular Evaluation and Management Services If the provider administering the LAI also performs a follow up visit on the same day of injection, they can bill for an E&M code in addition to billing for the injection procedure. Add Modifier.25 to the end of the E&M service code Significant, separately identifiable evaluation an management service by the same physician on the same day of the procedure or other service. Revenue Code Revenue codes categorize hospital services by revenue center to report cost data. 0250 General classification, Pharmacy 0510 Clinic 0636 Drugs requiring detailed coding Place of Service (POS) Codes POS 11, Office POS 22, Outpatient hospital POS 52, Psychiatric facility-partial Hospitalization POS 53, Community Mental Health Center
HCPCS Generic/Trade Approximate Retail Price NDC J1631 haloperidol decanoate 50 mg/ml (1 vial, 1 ml): $105.18 Varies by manufacturer 100 mg/ml (1 vial, 1 ml): $191.25 J2680 *fluphenazine decanoate 25 mg/ml (1 vial, 5 ml): $165.64 Varies by manufacturer J2794 risperidone microspheres 12.5 mg (1 syringe, 2 ml): $220.87 50458-0309-11 Risperdal Consta 25 mg (1 syringe, 2 ml): $439.20 50458-0306-11 37.5 mg (1 syringe, 2 ml): $657.58 50458-0307-11 50mg (1 syringe, 2 ml): $875.95 50458-0308-11 J2426 paliperidone palmitate 39 mg (1 syringe, 0.25 ml): $421.90 50458-0560-01 Invega Sustenna 78 mg (1 syringe, 0.5 ml): $815.80 50458-0561-01 117 mg (1 syringe, 0.75 ml): $1215.68 50458-0562-01 156 mg (1 syringe, 1 ml): $1622.65 50458-0563-01 234 mg ( 1 syringe, 1.5 ml): $2518.88 50458-0564-01 J2426 paliperidone palmitate 273 mg (1 syringe, 0.875mL): $2,333 50458-0606-01 Invega Trinza 410 mg (1 syringe, 1.315mL): $3.496.58 546 mg (1 syringe, 1.75mL): $4,660.27 50458-0607-01 50458-0608-01 50458-0609 819 mg (1 syringe, 2.625mL): $6,987.25 J2358 olanzapine pamoate 210 mg per vial (1 vial): $656.70 0002-07635-11 Zyprexa Relprevv 300 mg per vial (1 vial): $2029.01 0002-07636-11 405 mg per vial (1 vial): $1372.69 0002-07637-11
J0401 aripiprazole monohydrate 300 mg per vial (1 vial): $1491.62 59148-0018-71 Abilify Maintena 400mg per vial ( 1 vial): $1985.50 59148-0019-71 J0401 aripiprazole lauroxil 441mg (1 syringe, 1.6mL): $1,198.20 65757-0401-03 Abilify Aristada 662mg (1 syringe, 2.4mL): $1,795.50 65757-0402-03 883mg (1 syringe, 3.2mL): $2,367.55 65757-0403-03