Commonwealth of Massachusetts
Executive Office of Health and Human Services
Division of Medical Assistance
600 Washington Street
Boston, MA  02111

MassHealth
Nurse Practitioner Bulletin 8
September 1999

TO:      Nurse Practitioners Participating in MassHealth

FROM:      Mark E. Reynolds, Acting Commissioner

RE:      Obtaining Prior Authorization and Submitting Claims for Synagis (Palivizumab)

Introduction                      Synagis (palivizumab) is a medication used to prevent respiratory syncytial virus (RSV) infection in infants and children at increased risk for severe disease, in particular those born prematurely and those with chronic lung disease.

To ensure that Synagis is delivered correctly and appropriately to MassHealth members, the Division requires prior authorization before the administration of this drug to its members.  The Division’s criteria for evaluating prior-authorization requests for Synagis are based on the American Academy of Pediatrics guidelines for infants and children at high risk for developing RSV lower respiratory tract infection (attached). For each infant or child for whom prior authorization is granted, prior authorization will be issued for the duration of the RSV season, that is, the period of time during which RSV is most prevalent, usually from November through April.

Supplying Synagis             The two alternatives for reimbursement from the Division for supplying
Synagis are:

·     reimbursement to the MassHealth nurse practitioner for supplying
Synagis in the office; or

·     reimbursement to a MassHealth pharmacy provider if  the pharmacy provider delivers the Synagis to the nurse practitioner’s office.

Prior Authorization            To request prior authorization when a nurse practitioner supplies the Synagis, Requests When a               a Request for Prior Authorization form (sample attached) must be completed Nurse Practitioner              as described in the billing instructions in Subchapter 5 of the Physician Supplies the Synagis         Manual.  No other form, including letterhead, will be accepted for these prior-
authorization requests.

(continued on the back)

MassHealth
Nurse Practitioner Bulletin 8
September 1999
Page 2

Prior-Authorization            In item 3 of the prior-authorization form, enter the provider number of the Requests When a               practitioner who will be administering the Synagis.  Do not enter the group- Nurse Practitioner              practice provider number (the seven-digit number beginning with 97). Supplies the Synagis         Note: This instruction applies only when you are requesting prior
(cont.)                              authorization.  It does not change the way in which you enter provider numbers on the claim form.

Medical necessity must be documented in Item 11 of the prior-authorization form.  For determining medical necessity, the Division has adopted the guidelines of the American Academy of Pediatrics.  Refer to the Division’s criteria (attached) when detailing medical necessity in Item 11 of the prior- authorization form.

If a provider other than the one listed on the prior-authorization form will administer the Synagis, a new prior authorization must be obtained for that provider prior to service delivery.  Otherwise, the claim will be denied.

When a provider refers a member to another setting, such as an outpatient hospital or a community health center, the provider number of the outpatient hospital or community health center to which the member is being referred must be listed on the prior-authorization form.

Prior-Authorization            Prior authorization for Synagis supplied by a MassHealth pharmacy that Requests When the            delivers this drug to the nurse practitioner’s office must be requested by the Pharmacy Delivers             prescribing provider.  When this occurs, the prescribing provider must
the Synagis                       complete a Request for Prior Authorization form or submit a written request on letterhead containing the information required in the billing instructions in Subchapter 5 of the Physician Manual.  The request must include the name, address, and telephone number of the MassHealth pharmacy that will fill the prescription.

New Address for Prior-       Effective September 6, 1999, submit all prior-authorization requests for drugs
Authorization Requests      to the following address:
for Drugs
University of Massachusetts Medical School
DUR Program Offices
11 Midstate Drive
Auburn, MA 01501
Telephone #:  (508) 721-7171
Fax #:  (508) 721-7138

MassHealth
Nurse Practitioner Bulletin 8
September 1999
Page 3

Reimbursement                 Reimbursement requests for Synagis supplied in an office setting must be submitted on claim form no. 5.  Use Service Code X0415 to bill for Synagis. The claim must contain the name, strength, and dose of the drug.  A copy of the current invoice showing the actual acquisition cost must be attached to the claim form.  Claims will be denied if any required information or the invoice is missing.

Ensure that the prior-authorization number is written in Item 23D of claim form no. 5.  Also, verify that the provider number of the nurse practitioner administering the Synagis is identical to the provider number listed on the Division’s prior-authorization letter.  Otherwise, the claim will be denied.

Reimbursement requests for administration of the drug may also be listed on the claim form.  Do not use Service Code X0415 to bill for administration— use the appropriate administration service code from Subchapter 6 of the Physician Manual to bill for this service.

Obtaining Prior-                 To obtain supplies of the Request for Prior Authorization form, mail or fax
Authorization Forms          a written request to the following address or fax number.

Unisys
Attn: Forms Distribution
P.O. Box 9101
Somerville, MA 02145
Fax: (617) 576-4087

Questions                         If you have any questions about the information in this bulletin, please contact the Unisys Provider Services Department at (617) 628-4141 or
1-800-325-5231.