Site of service restrictions applied for infusion services April 1
Effective April 1, 2022, we’ll begin applying site-of-service restrictions for medication administration in accordance with our infusion services medical policy.
Beginning April 1, infusions for select medications must be administered at preferred sites of care, according to the member’s plan. If a non-preferred site of care is utilized after April 1, the claim will deny.
This change is in alignment with our existing medical policy. For medications included in this policy, commercial members are required to receive infusion services at a non-hospital location while Medicaid members must receive infusions at an outpatient hospital location. For more information, reference Medical Benefit Drug List.
The prior authorization requirement for Infliximab products was removed in May 2020 to remove administrative burden. Beginning April 1st, prior authorization is required for the continued administration of infliximab products at a non-preferred site of care. However, if a preferred site of care is utilized, according to the members plan, no authorization will be required.
Other infusion therapies
Beginning April 1, the site-of-service requirement is being applied to the medications listed below for new start Commercial members. Commercial members currently on these medications can continue at their site-of-service until their current authorization ends, up to July 1. 2022. For Medicaid members, no changes will occur, the site-of-service requirement is already in place.
What you need to do?
Member is enrolled in a commercial plan
If you have members 18 and older scheduled for infusion services at your provider location or facility for April and beyond, they need to be rescheduled at a preferred site-of-service for their plan.
Pediatric and adolescent commercial members can continue infusions at their current site-of-service.
Member is enrolled in a Medicaid plan
If you have members receiving infliximab infusions at a non-hospital location, they will need to be rescheduled at an outpatient hospital facility for April and beyond.
To avoid delays in care, specialists need to submit infusion orders with the preferred site-of-service for the member’s plan.