Site of Care Management Program
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Establishes a mandatory site-of-care program directing outpatient administration of select intravenous and subcutaneous specialty drugs to the most clinically appropriate, efficient, and cost-effective settings; applies to CareSource Georgia members and providers under the Marketplace product.
No material clinical or coverage changes in this revision.
Site-of-Care Coverage Criteria
Site-of-care medical necessity and default site criteria
Covered when ALL of the following are met:
ALL of the following
ONE of
- Member's condition is clinically unstable such that immediate access to hospital services may be required (examples include, but are not limited to, cardiopulmonary conditions, inability to safely tolerate intravenous volume loads, unstable vascular access).
- Member has physical or cognitive impairments such that immediate access to hospital services may be required.
- Member previously experienced a severe or potentially life‑threatening adverse event while receiving the requested medication (examples include, but are not limited to, anaphylaxis, seizure, thromboembolism, myocardial infarction, renal failure); additional monitoring is required. Documentation with dates and specific details of prior events and mitigation steps is required.
- Prescriber attests and documents that medication administration is not suitable for home infusion therapy AND no lower‑intensity setting is available.
- Clinical documentation (e.g., infusion records, medical records) supporting the exception must be included with dates and specific details of prior adverse reactions and mitigation steps taken.
Documentation must accompany prior authorization or request.
ALL of the following
- If the medical necessity criteria for hospital outpatient administration are NOT met, the drug must be administered in a non‑hospital outpatient setting (outpatient infusion facility such as ambulatory infusion center, ambulatory infusion suite, or provider office infusion center) or in the home.
- The Site of Care Management program mandates use of a non‑outpatient hospital setting that does not bill in accordance with an affiliated outpatient hospital (default site directive).
Providers must arrange administration in AIC/AIS/OIC or home when hospital outpatient criteria are not satisfied; exceptions require clinical documentation.
Billing and Site Coding Restrictions
| No codes listed |
Authorization, Documentation, and Provider Requirements
Site‑of‑care authorization and exception documentation
Providers must document medical necessity to justify administration of an outpatient hospital facility (HOPD). If the medical necessity criteria are not met, the drug must be administered in a non-hospital outpatient setting (outpatient infusion facility such as an ambulatory infusion center/suite, physician office, or home). Exceptions to the default non-hospital site require clinical documentation (infusion records, medical records) with dates and specific details of prior severe adverse events and mitigation steps.
- Document one or more medical necessity criteria: clinically unstable condition, physical/cognitive impairment requiring hospital access, prior severe/potentially life‑threatening adverse event with dates/details, or prescriber attestation that home/lower‑intensity settings are unsuitable.
- Include infusion records or medical records with dates and specific details of prior anaphylactic or other severe adverse reactions and steps taken to mitigate risk when requesting a hospital outpatient exception.
- If criteria are not met, arrange administration in an outpatient infusion facility (AIC/AIS/OIC) or home; the program mandates settings that do not bill as an affiliated outpatient hospital.
Site-of-Care Definitions
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