Infusion Alternative Site of Care - Commercial
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Defines criteria and prior authorization requirements determining when outpatient hospital facility-based intravenous medication infusion is medically necessary versus when alternative sites (non-hospital outpatient infusion, physician office, ambulatory infusion, or home infusion) are acceptable for Commercial, Wisconsin ETF, Self-Funded and Exchange members (Exchange starting 1/1/2025).
No material clinical or coverage changes in this revision.
Coverage Criteria: Site-of-Care Determination
Hospital Outpatient Infusion Medical Necessity
Covered when ANY of the following are met:
from policy detail A
from policy detail B
from policy detail C
from policy detail D
from policy detail E
from policy detail F
from policy detail G
Alternative Sites of Care (including non-hospital outpatient infusion, physician office, ambulatory infusion, or home infusion services) are acceptable places of service for specialty medication infusion when the patient does not meet the criteria requiring an outpatient hospital facility-based infusion. Use an Alternative Site of Care whenever the hospital outpatient infusion medical necessity criteria are not met.
Prior authorization through EviCore with submission of medical records is required. If Prior Authorization is not obtained, the drug and related service(s) will be denied with Claim Adjustment Reason Code CARC 197 ('Precertification/authorization/notification/pre-treatment absent').
Provider Actions, Prior Authorization & Documentation
Prior authorization required (EviCore)
Prior authorization is required through EviCore for infusion site determination; providers must obtain authorization via EviCore and use the EviCore Healthcare Continuum Prior Authorization Drug List which lists the codes requiring prior authorization.
- Authorization must be obtained through EviCore.
- Codes requiring prior authorization are listed on the EviCore Healthcare Continuum Prior Authorization Drug List.
Reference authorization list and site-of-care notation
Providers should reference the Network Health Pharmacy page for the authorization list and note that the site-of-care notation '±' is appended to drug list entries to indicate site-of-care requirements.
- The authorization list is located on Network Health's Pharmacy page: Pharmacy Information.
- Site of Care codes use the notation '±' behind the drug name.
Medical records required with prior authorization
Submission of medical records is required when requesting prior authorization through EviCore.
- Prior Authorization with the submission of medical records is required as part of the request.
Denial risk: missing prior authorization (CARC 197)
If prior authorization is not obtained, the drug and related services will be denied with Claim Adjustment Reason Code (CARC) 197.
- CARC 197 — 'Precertification/authorization/notification/pre-treatment absent'.
Denial / Coverage Coding
| CARC 197 | Precertification/authorization/notification/pre-treatment absent |
Acceptable Sites of Care
Acceptable alternative sites of care
Alternative Sites of Care (non-hospital outpatient infusion, physician office, ambulatory infusion, or home infusion) are acceptable when the patient does not meet the hospital outpatient infusion criteria; site-of-care determinations are made via the EviCore prior authorization list, which uses a '±' notation for site-of-care codes.
- Accepted settings include home, physician office, ambulatory infusion center, and hospital outpatient.
- Site-of-care codes on the EviCore list include a '±' notation appended to the drug name.
Definitions
Background
This policy governs site-of-care selection for specialty medication infusion and defines when outpatient hospital facility-based intravenous infusion is medically necessary versus when Alternative Sites of Care may be used. Alternative Sites of Care are defined as non-hospital outpatient infusion, physician office, ambulatory infusion, or home infusion services, and should be used if the patient does not meet any of the hospital outpatient infusion criteria. Authorization and specific site-of-care determinations are made through EviCore and the EviCore Healthcare Continuum Prior Authorization Drug List.
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