This policy update applies to Commercial and Exchange EmblemHealth Plans and ConnectiCare Plans.
This policy applies to ongoing Infusion maintenance treatment for members that are 21 years and older.
Starting for DOS August 1, 2022 and thereafter, EmblemHealth will start to review ongoing infusion treatments for Site of Services (Place of service).
Preferred POS locations:
o Home (Code 12):
▪ Location, other than a hospital or other facility, where the patient
receives care in a private residence.
o Office (Code 11):
▪ Includes Ambulatory Infusion Suite (AIS)
▪ Location, other than a hospital, skilled nursing facility (SNF), military
treatment facility, community health center, State or local public
health clinic, or intermediate care facility (ICF), where the health
professional routinely provides health examinations, diagnosis, and
treatment of illness or injury on an ambulatory basis.
Non-preferred POS locations would be:
o Off Campus-Outpatient Hospital (Code 19):
▪ A portion of an off-campus hospital provider-based department
which provides diagnostic, therapeutic (both surgical and
nonsurgical), and rehabilitation services to sick or injured persons
who do not require hospitalization or institutionalization.
o On Campus-Outpatient Hospital (Code 22):
▪ A portion of a hospital’s main campus which provides diagnostic,
therapeutic (both surgical and nonsurgical), and rehabilitation
services to sick or injured persons who do not require
hospitalization or institutionalization.
Exceptions apply and will be reviewed after the 6 month interval of treatment has been completed.
Also exceptions that are for initial doses and members with justifiable needs to continue care in a hospital outpatient setting will be allowed.
Prior authorization duration- current authorizations from Express Scripts’ company Care Continuum will be valid through the date noted in their approval letter.
However, after the current prior auth expires the providers should coordinate the administration of the medication in a preferred POS location.
Partial List of Medications that are covered in this policy and their exceptions.
For complete list of Medications and a whole Policy please click here.
Routine maintenance will be covered in the following outpatient settings:
- Home (POS 12)
- Office (POS 11)
- Ambulatory infusion suites (POS 24, POS 49, or POS 12 with Modifier SS)
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