Site of Care Management Program
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Defines CareSource Georgia's Site of Care Management Program directing administration of select medications to the least intensive appropriate setting for Marketplace members; affects Marketplace providers and members served by CareSource Georgia.
No material clinical or coverage changes in this revision.
Site of Care Coverage Criteria
Site-specific coverage criteria
Coverage is limited to lower-intensity sites of care except when medical necessity for hospital administration is documented and prior approval is obtained.
Prior authorization requests must include clinical documentation and be submitted via the Provider Portal or Medical Drug Fax 1-888-399-0271.
Therapies of focus
- Hereditary Angioedema
- HIV - Cabenuva and Apretude
- Immune Deficiencies
- Inflammatory Conditions
- Miscellaneous Diseases
- Multiple Sclerosis - Ocrevus, Ocrevus Zunovo
Therapies and Code List
| Hereditary Angioedema | Hereditary Angioedema |
| HIV - Cabenuva | HIV - Cabenuva |
| HIV - Apretude | HIV - Apretude |
| Immune Deficiencies | Immune Deficiencies |
| Inflammatory Conditions | Inflammatory Conditions |
| Miscellaneous Diseases | Miscellaneous Diseases |
| Multiple Sclerosis - Ocrevus | Multiple Sclerosis - Ocrevus |
| Multiple Sclerosis - Ocrevus Zunovo | Multiple Sclerosis - Ocrevus Zunovo |
Provider Requirements and Prior Authorization
Prior Authorization required for hospital-administered infusions
Infusions administered in a hospital outpatient setting are not eligible for reimbursement unless the provider obtains prior approval from CareSource demonstrating that hospital administration is medically necessary. Clinical documentation must be submitted with all exception (Prior Authorization) requests via the Provider Portal or by fax to the Medical Drug Fax at 1-888-399-0271.
- Obtain prior approval from CareSource before billing hospital-administered infusions unless medical necessity for hospital setting is documented.
- Submit supporting clinical documentation with every exception/Prior Authorization request.
- Use the Provider Portal or send documentation via Medical Drug Fax: 1-888-399-0271.
Key Definitions
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