Infusion & Injection Administration
Customize your policy alerts
Sign up for CareSource Georgia Policy Infusion & Injection Administration-MP-PY-1770 alerts
Get alerted when Policy Infusion & Injection Administration-MP-PY-1770 changes without checking for updates manually.
Monitor payer policy activity
Defines coding, billing, prior authorization, and reimbursement criteria for infusion and injection administration services for CareSource Georgia providers; applies to claims payment and provider billing processes.
No material clinical or coverage changes in this revision.
Coverage and Payment Criteria
inv-01: Administration coverage criteria
Coverage and payment conditions for administration services:
inv-02: Exclusions
Exclusions listed in the policy:
Medical Necessity Considerations
inv-11: Medical necessity
Medical necessity and coverage considerations:
Procedure, Supply, and Coding Requirements
| CPT/HCPCS | Use appropriate CPT/HCPCS codes that align with substance, route, and duration; follow AMA, NCCI, AHA, HCPCS, ICD-10, NDC, DRG and CCI guidelines. |
Prior Authorization and Provider Billing Actions
Verify and obtain prior authorization for high-cost/complex infusions
Certain high-cost medications and complex infusion therapies may require prior authorization. Providers should verify PA requirements by using the Procedure Code Lookup Tool on the CareSource website before submitting claims.
- Confirm whether a procedure code requires PA via the Procedure Code Lookup Tool on the CareSource website.
- Obtain and document prior authorization when the lookup indicates PA is required to avoid claim denials or delays.
Documentation and Recordkeeping Requirements
Use accurate CPT/HCPCS coding and provide documentation upon request
Submit accurate, appropriate CPT/HCPCS codes that align with the substance administered, route of administration, and total duration of the procedure, and retain supporting documentation; CareSource may request supporting documentation or perform post-payment verification.
- Use the most accurate CPT/HCPCS code(s) for the product or service according to AMA, NCCI, AHA, HCPCS, ICD-10, NDC, DRG and CCI guidance.
- Maintain and make available documentation of services performed (including administration details) upon CareSource request.
- Accurate coding and documentation is the submitting provider’s responsibility; inclusion of a code does not guarantee payment.
Key Definitions
Services Not Covered
The following services are not covered under this administration payment policy: chemotherapy and hydration administration, and home health visits. These exclusions mean administration fees described in this policy do not apply to chemotherapy/hydration infusions or to services billed as home health visits; providers should follow any separate policies or benefit rules that govern those services.
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.