#siteofcare – KR2 Medical Billing

Effective July 15, 2024- EmblemHealth will update their site of care policy and add 170 more injectable and infusion drugs to the list.

This change will apply to the commercial line of business and for all age groups.

The change is to help bring down the members’ cost sharing (out of pocket costs) and provide an access to the ongoing maintenance of infusion therapy.

The following is a partial list of these medications:

Note: for a full list of medications and the pdf version of site of care policy please visit – https://www.emblemhealth.com/providers/news/infusions-and-injectables-updates-policy-202404

These medications will still require prior authorization but will no longer be covered when administered in a hospital setting.

Instead the medications will be covered in the following place of service:

POS 11- Office

POS 12- Home

Ambulatory Infusion Suites- (POS 24, POS 49, or POS 12 with Modifier SS)

Exceptions for members that are receiving their first dosage may be requested with justifiable medical necessity.

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The following policy is effective 06/01/2021 and applies to Cigna Fully Insured and Self-Funded Plans.

Background: CMS and an evidence-based guidelines from MCG Health designate shoulder arthroplasty procedures (CPT codes 23470 & 23472) as outpatient, when medically appropriate.

Starting 06/01/2021- Cigna may deny CPT 23470 & 23472, when requested for inpatient level of care. (inpatient setting).

eviCore will review the inpatient level of care requests for medical necessity and level of care. eviCore will base its review of medical necessity based on MCG Health criteria.

Denials will include the medical necessity appeal rights.

The above policy is basically the site-of-care policy for Cigna Fully Insured and Self-Funded Plans.

Possible Solution to avoid unnecessary Denials: Make sure you review the Cigna Shoulder Arthroplasty Policy and CIGNA Site-of-Care Policy. Site-of-Care policy will give you the criteria for the patient to qualify for the inpatient setting and receive inpatient level of care as oppose to outpatient setting (ASC).

(Shoulder Arthroplasty Policy is updated for 07/01/2021) Please visit the links above for the FULL CIGNA POLICIES.

Tag: #siteofcare

EmblemHealth Commercial Plans: site of care change – adding 170 new injectable and infusion meds to the list

Cigna Update: Change to Shoulder Arthroplasty Coverage Review, 06/01/21

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