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

MassHealth
Outpatient Hospital Bulletin 41
September 1999

TO:      Outpatient Hospitals Participating in MassHealth

FROM:      Mark E. Reynolds, Acting Commissioner

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

Background                       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.

Prior-Authorization            To request prior authorization, a Request for Prior Authorization form
Requests                           (sample attached) must be completed as described in the billing instructions in Subchapter 5 of the Outpatient Hospital Manual.  No other form, including letterhead, will be accepted for prior-authorization requests.

In Item 3 of the prior-authorization form, enter the provider number of the outpatient hospital.  Medical necessity must be documented in Item 11. 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 outpatient hospital listed on the prior- authorization form will supply the Synagis, a new prior-authorization request must be obtained for that provider prior to service delivery. Otherwise, the claim will be denied.

MassHealth
Outpatient Hospital Bulletin 41
September 1999
Page 2

New Address for Prior-       Effective September 6, 1999, submit all prior-authorization requests for
Authorization Requests      drugs 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

Reimbursement                 Reimbursement requests for Synagis supplied by an outpatient hospital 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 outpatient hospital supplying 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 Outpatient Hospital 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.