The nearest or most accessible hospital that can treat you is a foreign hospital rather than a U.S. hospital. Attachment for PIP providers . The Contractor will process claims with the JA modifier still applying the policy as stated in the, Non-Excluded CPT/HCPCS Ended Codes - Table Format, Medicare BPM Ch 15.50.2 SAD Determinations, Article - Self-Administered Drug Exclusion List: (A52571). complete information, CMS does not guarantee that there are no errors in the information displayed on this web site. The CMS.gov Web site currently does not fully support browsers with Mechanicsburg, PA 17055-0709. Therefore, this is a dynamic site . PDF FIRSTCOAST AND SERVlCE OPTIONS, INC. WHEN ExPERIENCE COUNTS Patients Request for Medical Payment for the Influenza/Pneumococcal Vaccinations, Part B Services, (includes physician, laboratory, imaging services), Durable Medical Equipment, Prosthetics, Orthotics and Supplies, Foreign Travel (including Canada and Mexico) and Shipboard Services. In these situations, Medicare will pay for the Medicare-covered services you get in the foreign hospital and the physician and ambulance services furnished in connection with that foreign inpatient hospital stay. For drugs that have previously been covered as an integral part of the procedure, (e.g., a topical ophthalmic anesthetic is not separately reimbursed but is considered part of the fee for the procedure), there is no change. Self-Administered Drug (SAD) Exclusion List articles list the CPT/HCPCS codes that are excluded from coverage under this category. An asterisk (*) indicates a required field. GuideWell Source Careers at Novitas Solutions | Novitas Solutions Job Opportunities First Coast Locations & Hours Near Mechanicsburg, PA - YP.com You may also contact us at ub04@aha.org. TTY users should call 1-877-486-2048. Claims: Additional development requests (within 30 days of initial request) N/A. Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. TTY users should call 1-877-486-2048 This Agreement will terminate upon notice if you violate its terms. A federal government website managed and paid for by the U.S. Centers for Medicare & Medicaid Services. 10/31/2016 - The following drugs have been evaluated by First Coast Service Options, Inc. and have been determined to be usually self-administered drugs: Alprostadil Urethral Suppository (MUSE), Mecasermin (Increlex), Octreotide Non-Depot form (Sandostatin), Urofollitropin (Bravelle), Interferon Alfacon-1, Recombinant 1 Microgram, Interferon, Alfa-2A, Recombinant 3 million units, Interferon, GAMMA 1-B, 3 Million units, Actimmune Pegylated Interferon Alfa-2A (Peglntron), Pramlintide Acetate (Symlin), TriMix, Liraglutide (Saxenda), Pegvisomant (Somavert), Daclizumab (Zinbryta), Insulin glargine (Toujeo) Sermorelin Acetate, Pasireotide Long Acting 1 mg-J2502 and Taltz (Ixekizumab). Making copies or utilizing the content of the UB-04 Manual, including the codes and/or descriptions, for internal purposes, resale and/or to be used in any Check the box that applies to this claim, B. Subcutaneously administered drugs listed on the Usually Self-Administered list will be denied as a benefit exclusion. Some older versions have been archived. When you submit your own claim to Medicare, complete the entire form. Make a copy of your claim submission for your records and allow at least 60 days for Medicare to receive and process your request. The JB modifier must be billed for the subcutaneous form of the drug. No portion of the American Hospital Association (AHA) copyrighted materials contained within this publication may be copied without the express written consent of the AHA. For drugs that have multiple indications and routes of administration, contractors will consider all of the indications and routes of administration when making a single determination for a drug.Contractors must continue to apply the policy that not only is the drug medically reasonable and necessary for any individual claim, but also that the route of administration is medically reasonable and necessary. Applicable FARS/HHSARS apply. Payment for drugs and supplies used in the performance of procedures is included in the fee for the procedure and are not separately billable to Medicare or the beneficiary.Congress changed the Medicare definition of the type of drugs that cannot be self-administered with passage of the Medicare, Medicaid, and State Childrens Health Insurance Program (SCHIP) Benefits Improvement and Protection Act (BIPA) of 2000 to usually not self-administered. apply equally to all claims. If the claim form has incomplete or invalid information, the Medicare contractor will return the claim along with a letter to you clearly stating what information is missing or invalid. Search results are sorted by a combination of factors to give you a set of choices in response to your search criteria. Medicare will not process a beneficiary request for payment for diabetic test strips, Part B drugs, or for items paid for under the DMEPOS Competitive Bidding program. The responsibility for the content of this file/product is with CMS and no endorsement by the AMA is intended or implied. You can decide how often to receive updates. Absent evidence to the contrary, the Contractor presumes that drugs delivered intravenously are not usually self-administered by the patient. Claims for drugs marked with an asterisk (*) billed without either a JA or JB modifier will also be denied. 04/02/2018 - Article revised and posted for notice on 02/08/2018 to add Haegarda (C1 Esterase Inhibitor Subcutaneous [Human]) (J3490/J3590) effective for dates of service on or after 04/02/2018. Thank you for visiting First Coast Service Options' Medicare provider website. TTY users should call 1-877-486-2048. You can use the Contents side panel to help navigate the various sections. The document is broken into multiple sections. It is very important the provider who treated you be identified. Mechanicsburg, PA 17055-1849. CPT codes, descriptions and other data only are copyright 2021 American Medical Association. Please note that if you choose to continue without enabling "JavaScript" certain functionalities on this website may not be available. First Coast Service Options, Inc. Jacksonville, FL 32202 Cunningham, Carolyn, M.D. 3767 0 obj <> endobj If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Baltimore, Maryland 21244-1850, An official website of the United States government, CMS 1490S: Patients Request For Medical Payment, Your reason for submitting this claim: (see the Instructions for additional information, check one box only). or HCPCS code J2502 has been removed from the article as it is IM administration and therefore is not considered self-administered. that coverage is not influenced by Revenue Code and the article should be assumed to apply equally to all Revenue Codes. CMS 1490S: Patient's Request For Medical Payment | CMS Many times a bill will show the names of several doctors or suppliers. First Coast - E/M Services: Preparing for the 2021 Changes (B) Providers will be given a 45-day notice period if a previously covered drug is determined to be non-covered. If you are acting on behalf of an organization, you represent that you are authorized to act on behalf of such organization and that your acceptance of the terms of this agreement creates a legally enforceable obligation of the organization. Drugs that fall under this category will be marked with an asterisk (*) and must be billed with JA modifier for the intravenous infusion of the drug or billed with the JB modifier for subcutaneous form of administration. Medicare does not pay for the hepatitis B vaccines. Sign up to get the latest information about your choice of CMS topics. Determine % utilization by clinical indication and route of administration. Applicable Federal Acquisition Regulation Clauses (FARS)/Department of Defense Federal Acquisition Regulation supplement (DFARS) Restrictions Apply to Government Use. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely. Instructions for enabling "JavaScript" can be found here. It is also used to decide if the services and supplies you received are covered by Medicare and to insure that proper payment is made. You live in the U.S. and the foreign hospital is closer to your home than the nearest U.S. hospital that can treat your medical condition, regardless of whether its an emergency. The valid OMB control number for this information collection is 0938-1197. Medicare determines what qualifies as without unreasonable delay on a case-by-case basis. Sometimes, a large group can make scrolling thru a document unwieldy. Contractors may specify Bill Types to help providers identify those Bill Types typically Manual or any portion thereof, including the codes and/or descriptions, is only authorized with an express license from the American Hospital Association. License to use CDT for any use not authorized herein must be obtained through the American Dental Association, 211 East Chicago Avenue, Chicago, IL 60611. Do you have any medical coverage other than Medicare, such as private insurance, MEDIGAP, employment related insurance, Medicaid,or the Veterans Administration (VA)? There are different article types: Articles are often related to an LCD, and the relationship can be seen in the "Associated Documents" section of the Article or the LCD. CPT is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. product or publication; creating any modified or derivative work of the UB-04 Manual and/or codes and descriptions; and/or making any commercial use of UB-04 All other provider types ( not on the certified list mentioned above) should submit directly to First Coast: First Coast Service Options, Inc. Medicare Reconsideration Request. Medicare, click here - First Coast Service Options, Inc. - fcso.com The issues arise with the drugs that are given by intravenous (IV), intramuscular (IM), subcutaneous (SQ) or multiple routes of administration.These transmittals instruct each individual contractor to develop a process for the determination on each drug. hbbd``b`$W \\ "} D+d100?0 Box 6720 Fargo, ND 58108-6720: https://med.noridianmedicare.com/ Part B Contractor Noridian Healthcare Solutions 877-908-8431 Absent evidence to the contrary, the Contractor presumes that drugs delivered intravenously are not usually self-administered by the patient. YP, the YP logo and all other YP marks contained herein are trademarks of YP LLC and/or YP affiliated companies. article does not apply to that Bill Type. If a physician or supplier furnishes Medicare covered services to you and refuses to submit a claim on your behalf for those services, please call 1-800-MEDICARE (1-800-633-4227) in order to file a complaint with the Medicare contractor. https://medicare.fcso.com/Self-administered_drugs/ Exenatide extended release for injectable suspension (Bydureon), Acceptable Evidentiary Criteria Available, Presumption of Long-Term Non-Acute Administration, Albiglutide for SQ injection (Tanzeum) 30mg, Skyrizi (risankizumab-rzaa, injection for subcutaneous use)*, Kesimpta* (ofatumumab, injection for subcutaneous use), INJECTION, ABATACEPT, 10 MG (CODE MAY BE USED FOR MEDICARE WHEN DRUG ADMINISTERED UNDER THE DIRECT SUPERVISION OF A PHYSICIAN, NOT FOR USE WHEN DRUG IS SELF ADMINISTERED), INJECTION, ALPROSTADIL, 1.25 MCG (CODE MAY BE USED FOR MEDICARE WHEN DRUG ADMINISTERED UNDER THE DIRECT SUPERVISION OF A PHYSICIAN, NOT FOR USE WHEN DRUG IS SELF ADMINISTERED), ALPROSTADIL URETHRAL SUPPOSITORY (CODE MAY BE USED FOR MEDICARE WHEN DRUG ADMINISTERED UNDER THE DIRECT SUPERVISION OF A PHYSICIAN, NOT FOR USE WHEN DRUG IS SELF ADMINISTERED), INJECTION, APOMORPHINE HYDROCHLORIDE, 1 MG, INJECTION, LANADELUMAB-FLYO, 1 MG (CODE MAY BE USED FOR MEDICARE WHEN DRUG ADMINISTERED UNDER DIRECT SUPERVISION OF A PHYSICIAN, NOT FOR USE WHEN DRUG IS SELF-ADMINISTERED), INJECTION, C-1 ESTERASE INHIBITOR (HUMAN), (HAEGARDA), 10 UNITS, INJECTION, CALCITONIN SALMON, UP TO 400 UNITS, INJECTION, ETANERCEPT, 25 MG (CODE MAY BE USED FOR MEDICARE WHEN DRUG ADMINISTERED UNDER THE DIRECT SUPERVISION OF A PHYSICIAN, NOT FOR USE WHEN DRUG IS SELF ADMINISTERED), INSULIN FOR ADMINISTRATION THROUGH DME (I.E., INSULIN PUMP) PER 50 UNITS, INJECTION, INTERFERON BETA-1B, 0.25 MG (CODE MAY BE USED FOR MEDICARE WHEN DRUG ADMINISTERED UNDER THE DIRECT SUPERVISION OF A PHYSICIAN, NOT FOR USE WHEN DRUG IS SELF ADMINISTERED), INJECTION, OCTREOTIDE, NON-DEPOT FORM FOR SUBCUTANEOUS OR INTRAVENOUS INJECTION, 25 MCG, INJECTION, SUMATRIPTAN SUCCINATE, 6 MG (CODE MAY BE USED FOR MEDICARE WHEN DRUG ADMINISTERED UNDER THE DIRECT SUPERVISION OF A PHYSICIAN, NOT FOR USE WHEN DRUG IS SELF ADMINISTERED), INJECTION, FREMANEZUMAB-VFRM, 1 MG (CODE MAY BE USED FOR MEDICARE WHEN DRUG ADMINISTERED UNDER THE DIRECT SUPERVISION OF A PHYSICIAN, NOT FOR USE WHEN DRUG IS SELF-ADMINISTERED), USTEKINUMAB, FOR SUBCUTANEOUS INJECTION, 1 MG, pegylated interferon alfa-2b) (PegIntron), Exenatide extended release for injectable suspension Bydureon(), albiglutide for SQ injection (Tanzeum) 30mg, Exenatide extended release for injectable suspension [Bydureon()], INJECTION, INTERFERON ALFACON-1, RECOMBINANT, 1 MICROGRAM, INJECTION, INTERFERON, ALFA-2A, RECOMBINANT, 3 MILLION UNITS, INJECTION, INTERFERON, GAMMA 1-B, 3 MILLION UNITS, INJECTION, SERMORELIN ACETATE, 1 MICROGRAM, INJECTION, IMMUNE GLOBULIN (XEMBIFY), 100 MG, INJECTION, IMMUNE GLOBULIN (HIZENTRA), 100 MG, Haegarda (C1 Esterase Inhibitor Subcutaneous [Human]).
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