CurrentCommunity Health ChoicePolicy N/A

Clinician Administered Drugs Site of Care Policy

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Governs the site of care for medication infusion services provided in hospital outpatient facilities to Community Health Choice members aged 18 years or older when billed under Place of Service 19 or 22. Hospital outpatient infusion is covered only when documented clinical, adherence, or pharmacy-timeliness factors make a non-hospital site inappropriate; additional medication-specific prior authorization may apply.

Policy Summary

PayerCommunity Health Choice

PolicyClinician Administered Drugs Site of Care Policy

Policy CodePolicy N/A

Change TypeRevisedpembrolizumab and nivolumab codes added

Effective DateAug 1, 2025

Next Review DateN/A

Key ActionSubmit documentation and an attestation explaining why a non-hospital infusion site would create a qualifying clinical, adherence, or pharmacy-delivery risk.

SourceLink

POLICY UPDATE CHANGES

The policy was updated effective April 1, 2025, in accordance with HB1647.

Pembrolizumab and nivolumab were added to the applicable drug codes effective August 1, 2025.

18+Minimum patient age subject to the policy

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CurrentCommunity Health ChoicePolicy N/A

Clinician Administered Drugs Site of Care Policy

Customize your policy alerts

Sign up for all communityhealthchoice policy alerts

Know when communityhealthchoice releases new policies or updates existing guidance.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Policy Summary

PayerCommunity Health Choice

PolicyClinician Administered Drugs Site of Care Policy

Policy CodePolicy N/A

Change TypeRevisedpembrolizumab and nivolumab codes added

Effective DateAug 1, 2025

Next Review DateN/A

Key ActionSubmit documentation and an attestation explaining why a non-hospital infusion site would create a qualifying clinical, adherence, or pharmacy-delivery risk.

SourceLink

POLICY UPDATE CHANGES

The policy was updated effective April 1, 2025, in accordance with HB1647.

Pembrolizumab and nivolumab were added to the applicable drug codes effective August 1, 2025.

18+Minimum patient age subject to the policy

Hospital outpatient place-of-service codes covered by the policy

4Alternative non-hospital site types identified

6 monthsMaximum approval period before reassessment

17Applicable clinician-administered drug codes

Hospital Outpatient Infusion Coverage Criteria

Hospital-based Outpatient Infusion Criteria

Hospital-based outpatient medication infusion is medically necessary when all applicability requirements are met and at least one qualifying exception to non-hospital infusion is documented.

Hospital outpatient applicability: The patient is 18 years of age or older and the infusion is provided in a hospital outpatient facility under Place of Service 19 or 22.Age >= 18; POS 19 or POS 22

Infusion services for patients under 18 are not subject to this policy.

Qualifying reason for hospital outpatient site

Clinical harm or progression: Use of a non-hospital site would make patient harm, death, or disease progression probable.Probable harm, death, or disease progression
Adherence or compliance barrier: Use of a non-hospital site would potentially cause a barrier to adherence or compliance with the plan of care.Potential barrier to adherence or compliance
Timeliness, dosage, or pharmacy requirement: Timeliness of delivery or dosage requirements would necessitate delivery by a different pharmacy.Different pharmacy required

Documentation and attestation: The provider submits documentation and attestation supporting the applicable qualifying reason for hospital outpatient infusion.Documentation plus attestation

Approval is limited to 6 months for reassessment.

This policy applies to hospital outpatient medication infusion services for patients 18 years of age or older. Infusion services provided to patients younger than 18 years are not subject to this policy.

In a non-emergency situation, a medically stable patient should receive the infusion at an appropriate non-hospital site when changing sites is not expected to cause disease progression, member harm, or a barrier to regimen compliance. Appropriate sites include non-hospital outpatient infusion centers, physician offices, ambulatory infusion centers, and home infusion services.

Hospital outpatient infusion is not medically necessary when the submitted documentation and attestation do not establish that use of a non-hospital site would make patient harm, death, or disease progression probable; potentially create a barrier to adherence or compliance with the plan of care; or require delivery by a different pharmacy because of timeliness or dosage requirements.

Applicable Drug Codes

Applicable Codes - Clinician-administered drugs, group 1mixed

00310-1730-30	NDC Label Name = FASENRA 30 MG/ML SYRINGE; HCPCS = J0517
J0517	FASENRA 30 MG/ML SYRINGE
00310-1830-30	NDC Label Name = FASENRA PEN 30 MG/ML; HCPCS = J0517
25682-0001-01	NDC Label Name = SOLIRIS 300 MG/30 ML VIAL; HCPCS = J1300
J1300	SOLIRIS 300 MG/30 ML VIAL
64764-0300-20	NDC Label Name = ENTYVIO 300 MG VIAL; HCPCS = J3380
J3380	ENTYVIO 300 MG VIAL
76125-0900-02	NDC Label Name = GAMMAKED 1 GRAM/10 ML VIAL; HCPCS = J1561
76125-0900-26	NDC Label Name = GAMMAKED 2.5 GRAM/25 ML VIA; HCPCS = J1561
J1561	GAMMAKED

1–10 of 25

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Applicable Codes - Clinician-administered drugs, group 2mixed

00069-0249-01	Injection, rituximab-pvvr, biosimilar, (ruxience), 10 mg; HCPCS = Q5119
0069-0238-01	Injection, rituximab-pvvr, biosimilar, (ruxience), 10 mg; HCPCS = Q5119
Q5119	Injection, rituximab-pvvr, biosimilar, (ruxience), 10 mg
55513-224-01	Injection, rituximab,arrx, biosimilar, (Riabni), 10 mg; HCPCS = Q5123
55513-326-01	Injection, rituximab,arrx, biosimilar, (Riabni), 10 mg; HCPCS = Q5123
Q5123	Injection, rituximab,arrx, biosimilar, (Riabni), 10 mg
57894-0030-01	Injection, infliximab, excludes biosimilar, 10 mg per unit; HCPCS = J1745
57894-0160-01	Injection, infliximab, excludes biosimilar, 10 mg per unit; HCPCS = J1745
J1745	Injection, infliximab, excludes biosimilar, 10 mg per unit
78206-0162-01	Injection, INFLIXIMAB-ABDA, (RENFLEXIS), 10 MG; HCPCS = Q5104

1–10 of 25

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Authorization and Documentation Requirements

Prior Authorization

Hospital Outpatient Approval and Medication Authorization

Hospital outpatient medication infusion requires approval under the hospital-based outpatient infusion criteria. Approval is limited to 6 months for reassessment, and additional prior authorization may be required for the requested medication.

Applies to the site of care where the patient receives the infusion.
Reassess the patient's ability to receive treatment at an alternative non-hospital site after 6 months.

Documentation Required

Document the Hospital-Site Exception

Requests for hospital outpatient infusion must include documentation and an attestation explaining why use of a non-hospital infusion site would create a clinically significant risk or compliance barrier.

Make patient harm, death, or disease progression probable.

Policy Background

This policy is a site-of-care utilization guideline for clinician-administered medication infusions. It promotes administration in non-hospital settings when clinically appropriate for medically stable patients, while permitting hospital outpatient infusion when changing sites could create serious clinical harm, compromise adherence or compliance, or conflict with pharmacy delivery or dosage requirements. Hospital outpatient approval is limited to 6 months so the patient's ability to transition to an alternative site can be reassessed.

Place of Service and Alternative Sites

Place of Service 19

Place of Service code19

DefinitionOff Campus-Outpatient Hospital

Policy applicabilityMedication infusion services provided by hospital outpatient facilities to patients who are 18 years of age or older

Place of Service 22

Place of Service code22

DefinitionOn Campus-Outpatient Hospital

Policy applicabilityMedication infusion services provided by hospital outpatient facilities to patients who are 18 years of age or older

Initial Hospital Outpatient Site Approval

Initial hospital outpatient site approval applies to listed clinician-administered drugs when all of the following are met:

Listed drug and hospital outpatient setting: The requested service is medication infusion for a clinician-administered drug listed in the applicable codes and is provided in a hospital outpatient facility under Place of Service 19 or 22 for a patient aged 18 years or older.Listed applicable drug; age >= 18; POS 19 or POS 22

Additional medication-specific prior authorization may be required.

Qualifying exception to non-hospital care

Clinical harm or progression: Use of a non-hospital site would make patient harm, death, or disease progression probable.Probable harm, death, or disease progression

Continued Hospital Outpatient Site Approval

Reassessment for Continued Hospital Outpatient Site

Continued hospital outpatient infusion approval requires reassessment after the limited approval period.

Six-month reassessment: Hospital outpatient medication infusion approval is limited to 6 months to allow reassessment of the patient's ability to receive treatment at an alternative non-hospital site of care.6 months

The policy does not provide additional continuation criteria.

Appropriate Infusion Site Selection

Note

Use a non-hospital outpatient infusion center

Use a non-hospital outpatient infusion center when clinically appropriate for a medically stable patient in a non-emergency situation and a change in site is not expected to cause disease progression, member harm, or a barrier to regimen compliance.

Note

Use a physician office when appropriate

Use a physician office when clinically appropriate for a medically stable patient in a non-emergency situation and a change in site is not expected to cause disease progression, member harm, or a barrier to regimen compliance.

Note

Use an ambulatory infusion center

Use an ambulatory infusion center when clinically appropriate for a medically stable patient in a non-emergency situation and a change in site is not expected to cause disease progression, member harm, or a barrier to regimen compliance.

Policy Summary

PayerCommunity Health Choice

PolicyClinician Administered Drugs Site of Care Policy

Policy CodePolicy N/A

Change TypeRevisedpembrolizumab and nivolumab codes added

Effective DateAug 1, 2025

Next Review DateN/A

Key ActionSubmit documentation and an attestation explaining why a non-hospital infusion site would create a qualifying clinical, adherence, or pharmacy-delivery risk.

SourceLink

On This Page

Potentially cause a barrier to the patient's adherence or compliance with the plan of care.

Because of timeliness of delivery or dosage requirements, necessitate delivery by a different pharmacy.

Denial Risk

Failure to Meet Hospital-Site Criteria

Hospital-based outpatient infusion does not meet this policy's site criteria when the patient is under 18, the service is billed outside the applicable hospital outpatient Place of Service codes, or the required documentation, attestation, or site-of-care criteria are not satisfied.

Patient must be 18 years of age or older.
Applicable Place of Service codes are 19 (off-campus outpatient hospital) and 22 (on-campus outpatient hospital).
Infusion services for patients under 18 are not subject to this policy; requests that do not satisfy the hospital-site requirements may be denied or redirected.

Note

Appropriate Alternative Site Available

In non-emergency situations, a medically stable patient may be required to receive medication infusion at an appropriate non-hospital site when changing sites is not expected to cause disease progression, member harm, or a barrier to regimen compliance.

Non-hospital outpatient infusion center
Physician office
Ambulatory infusion center
Home infusion services

Alternative Non-Hospital Sites of Care

Clinical useUse when clinically appropriate in non-emergency situations for medically stable patients when changing sites is not expected to result in disease progression, member harm, or a barrier to regimen compliance

Outpatient infusion centersNon-hospital outpatient infusion centers

Physician officePhysician office

Ambulatory infusion centersAmbulatory infusion centers

Home infusionHome infusion services

Adherence or compliance barrier: Use of a non-hospital site would potentially cause a barrier to adherence or compliance with the plan of care.Potential barrier to adherence or compliance

Timeliness, dosage, or pharmacy requirement: Timeliness of delivery or dosage requirements would necessitate delivery by a different pharmacy.Different pharmacy required

Note

Use home infusion when appropriate

Use home infusion services when clinically appropriate for a medically stable patient in a non-emergency situation and a change in site is not expected to cause disease progression, member harm, or a barrier to regimen compliance.

Prior Authorization

Use hospital outpatient infusion only when criteria are met

Hospital outpatient infusion may be used when the patient meets the hospital-based outpatient infusion criteria and documentation supports a qualifying risk from use of a non-hospital site. Approval is limited to 6 months for reassessment of the patient's ability to receive treatment at an alternative non-hospital site of care.

The qualifying risk may involve probable patient harm, death, or disease progression.
The qualifying risk may involve a potential barrier to adherence or compliance with the plan of care.
The qualifying risk may involve pharmacy delivery timeliness or dosage requirements.