| Health Plan | Process for Reimbursement | Electronically Accept Unlisted Code (specify the unlisted code) and NDC Code |
|---|---|---|
| Aetna Health, Inc.; and Aetna Life Insurance Company | Aetna is able to accept the inclusion of the National Drug Code (NDC) on the initial ED claim electronically. It does not require a manual process. If we receive an electronic claim that includes both the unlisted code J3490 and the NDC code, we can process it electronically. The unlisted code will trigger our threshold logic. If the billed amount is less than the limit, it will auto-allow the claim. If the billed amount exceeds the threshold, it will then drop for clinical review | Yes for unlisted code J3490 and NDC code |
| Blue Cross and Blue Shield of MA, Inc. and Blue Cross and Blue Shield of Massachusetts, Inc. | It would be best filed as a pharmacy claims. If filed as a medical claim, BCBSMA systems would require manual processing of any claims associated with an ED revenue code and case rate. Although an NDC code may make pricing more straightforward, a claim associated with an ED revenue code would most likely need to be denied and approved on appeal. | N/A |
| BMC Health Net Plan, Inc. d/b/a Wellsense Health Plan | Claims for nasal naloxone in the ED must include revenue code 636, HCPCS code J3490, modifier HG, and the NDC. | Must be reported with HCPCS code J3490, modifier HG and the NDC |
| Cigna Health & Life Insurance Company | We accept the code J3490 and the code would be processed according to the member’s medical benefits and the provider’s contract. Under certain contract arrangements we would need to know the name and NDC number before we could reimburse a charge submitted with J3490. Depending on the contract arrangement with the facility, we could process the charge for the J3490 separate from other charges and in other cases the J3490 will be bundled into the overall Emergency Room (ER)/facility rate. | Yes, for unlisted code J3490 and NDC code. |
| ConnectiCare of Massachusetts, Inc. | ConnectiCare of Massachusetts, Inc. accepts the code J3490 and manually processes the claim, because we ask for the name and NDC number of the drug that would be paid under the medical benefit. | N/A |
| Fallon Community Health Plan, Inc.; and Fallon Health and Life Assurance Company | Fallon Health will accept a charge for a naloxone kit billed under code J3490. The claim must include the NDC code. Claims may be submitted electronically. Depending on contract arrangements, the charge may be bundled into the overall ER charge or may be paid as a separate line item. | N/A |
| Harvard Pilgrim Health Care, Inc.; and HPHC Insurance Company | Harvard Pilgrim reimburses for nasal naloxone when billed using a pharmacy revenue code, unlisted code J3490, and the nasal naloxone NDC (Note: If a specific HCPCS code for nasal naloxone becomes available that code will be required rather than the unlisted drug code). Please refer to Harvard Pilgrim’s Injectable and Implantable Outpatient Drugs Payment Policy for additional billing details. | Yes, for unlisted code J3490 and NDC code |
| Health New England, Inc. | HNE accepts the unlisted J3490 code for the purpose of billing and reimbursement for nasal naloxone, processed according to both the member’s benefit and the provider contract. If the provider is not contracted with HNE to be reimbursed for that code, it will deny as a noncontracted provider. In instances where they are contracted it will either pay on that line where the code was billed, or it is bundled as a global payment. | N/A |
| Mass General Brigham Health Plan, Inc. | EDs bill under the J3490 code and would need to record the NDC for the Naloxone Kit on the claim or submit that information separately per the unlisted code process outlined on the General Billing and Coding Provider Payment Guidelines. | HCPCS – J3490 and NDC for Naloxone kits |
| Tufts Associated Health Maintenance Organization, Inc.; and Tufts Insurance Company | Tufts Health Plan reimburses ED services to facilities and professionals according to the applicable contracted agreement. Our compensation arrangements sometimes include bundling, where drugs could be factored into the reimbursement for other services. In these instances, the payment for nasal naloxone disbursement is included as part of the bundled payment. If the contract does not include a bundled rate for drugs, then the ED should follow the process outlined in the Tufts Health Plan payment policy/provider manual governing unlisted or not otherwise classified codes, including for codes 99199 and J3490, to receive separate reimbursement for nasal naloxone. For Tufts Health Plan Commercial providers, see the following payment policy: Point32Health Provider Manual Payment Policies. For Tufts Health Public Plans providers, see unlisted code section in the Tufts Health Public Plans Provider Manual. The payment policy/provider manual outline the same process to submit claims with unlisted codes. Providers are required to submit a PAPER claim with supporting documentation as specified therein. Unlisted or miscellaneous drug codes not currently covered by a HCPCS code, such as nasal naloxone must include an invoice with the claim that includes the drug name, appropriate NDC number and dosage. | N/A |
| Tufts Health Public Plans, Inc | Tufts Health Plan reimburses emergency department services to facilities and professionals according to the applicable contracted agreement. Our compensation arrangements sometimes include bundling, where drugs could be factored into the reimbursement for other services. In these instances, the payment for nasal naloxone disbursement is included as part of the bundled payment. If the contract does not include a bundled rate for drugs, then the ED should follow the process outlined in the Tufts Health Plan payment policy/provider manual governing unlisted or not otherwise classified codes, including for codes 99199 and J3490, to receive separate reimbursement for nasal naloxone. Payment policy for Tufts Health Plan Commercial providers. For Tufts Health Public Plans providers, see unlisted code section in the Tufts Health Public Plans Provider Manual. The payment policy/provider manual outline the same process to submit claims with unlisted codes. Providers are required to submit a PAPER claim with supporting documentation as specified therein. Unlisted or miscellaneous drug codes not currently covered by a HCPCS code such as nasal naloxone must include an invoice with the claim that includes the drug name, appropriate National Drug Code (NDC) number and dosage. | N/A |
| UnitedHealthcare Insurance Company | Payment to an ER for nasal naloxone kits depends on how the ER provider contract is constructed. If the contract has no drug carve out for each ER visit, payment for the drug will not be issued in addition to the ER visit payment. If the contract does contain a carve-out for drug revenue codes, the submission of the Centers for Medicare & Medicaid Services (CMS) unlisted code C9399 is required. C9399 will automatically default to the negotiated Percentage Payment Rate (PPR), which is a percent of billed charges, and a specific drug description is not necessary. Payment to the ER will issue electronically, and a paper submission isn’t required. If the ER does bill unlisted code J3490, it will pay at a $0.00 contract rate. As soon as a specific code is available for nasal naloxone kits, ERs must discontinue billing unlisted code C9399, and use the correct specific code | N/A |
Information for health providers regarding the processes, including appropriate billing codes, for reimbursement of Naloxone that is prescribed by an inpatient facility in Massachusetts.