ModifiedDHAPolicy 6010.61-M

Processing and Payment of Home Infusion Claims

Customize your policy alerts

Sign up for DHA Policy 6010.61-M alerts

Get alerted when Policy 6010.61-M changes without checking for updates manually.

Monitor payer policy activity

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

Requirements for processing and paying TRICARE claims for home infusion services, including provider eligibility, preauthorization, reimbursement, coding, pricing, and exclusions.

Policy Summary

PayerDHA

PolicyProcessing and Payment of Home Infusion Claims

Policy CodePolicy 6010.61-M

Change TypeModified

Effective DateN/A

Next Review DateN/A

Key ActionObtain preauthorization for home infusion services before providing them.

SourceLink

POLICY UPDATE CHANGES

Drugs infused through Durable Medical Equipment are priced at ASP plus 6 percent.

Medicare-denied home infusion claims with denial code PR-50 must be reviewed to distinguish benefit limitations from denials based on medical necessity.

Home infusion supplies billed with a visit are separately payable from the associated home infusion visit services.

PreauthorizationHome infusion service requirement

CMAC fee-for-serviceEligible CSP reimbursement

95% of AWPQualifying drug pricing

ASP + 6%

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.

ModifiedDHAPolicy 6010.61-M

Processing and Payment of Home Infusion Claims

Customize your policy alerts

Sign up for DHA Policy 6010.61-M alerts

Get alerted when Policy 6010.61-M changes without checking for updates manually.

Monitor payer policy activity

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

Requirements for processing and paying TRICARE claims for home infusion services, including provider eligibility, preauthorization, reimbursement, coding, pricing, and exclusions.

Policy Summary

PayerDHA

PolicyProcessing and Payment of Home Infusion Claims

Policy CodePolicy 6010.61-M

Change TypeModified

Effective DateN/A

Next Review DateN/A

Key ActionObtain preauthorization for home infusion services before providing them.

SourceLink

POLICY UPDATE CHANGES

Drugs infused through Durable Medical Equipment are priced at ASP plus 6 percent.

Medicare-denied home infusion claims with denial code PR-50 must be reviewed to distinguish benefit limitations from denials based on medical necessity.

Home infusion supplies billed with a visit are separately payable from the associated home infusion visit services.

PreauthorizationHome infusion service requirement

CMAC fee-for-serviceEligible CSP reimbursement

95% of AWPQualifying drug pricing

ASP + 6%

DME-infused drug pricing

3 supply codesSeparately payable supplies

PR-50Medicare denial review

Home Infusion Coverage and Payment Rules

Requirements for reimbursement

Home infusion payment is available when ALL of the following requirements are met:

ALL of the following

Home infusion services are preauthorized.
Services are provided in accordance with applicable TRICARE Policy Manual requirements.
Professional services, related drugs, and supplies are otherwise covered.
Services are provided by TRICARE-authorized individual providers employed by or under contract with an eligible freestanding Corporate Services Provider (CSP).

Nonreimbursable charges

The following amounts are excluded from reimbursement:

Any of the following

Additional facility charges that are not already incorporated into the professional service structure are not payable.
Additional provider expenses due to travel are not covered.

Basic home infusion payment requirements

Home infusion services are payable when ALL of the following requirements are met:

ALL of the following

The service is preauthorized.
The service is provided in accordance with TPM Chapter 8, Section 20.1.
The professional service is furnished by a TRICARE-authorized individual provider employed by or contracted with an eligible freestanding Corporate Services Provider (CSP).

Payment limitations and exclusions

Payment is subject to ALL of the following service, pricing, coding, and exclusion rules:

ALL of the following

Services, drugs, and supplies are otherwise covered.
Drugs and supplies are billed using the applicable coding and pricing requirements.
Additional facility charges outside the professional service structure and provider travel expenses are not payable.
Administrative charges or expenses incorporated into home infusion S-code per diems are not payable.

Medicare denial adjudication

Medicare-eligible home infusion claims with denial code PR-50 must be classified before TRICARE payment is determined:

One of the following outcomes applies

The Medicare denial reflects a benefit limitation; TRICARE pays as primary.
The Medicare denial is unrelated to a benefit limitation, including a denial based on medical necessity; TRICARE denies the claim.

Codes, Pricing, and Separately Payable Supplies

Home infusion drug coding and pricing identifiersmixedCovered

J codes	Appropriate HCPCS J code required for home infusion drugs.
J-3490	Unclassified drug code may be used for reporting when the FDA-approved drug has a specific NDC for pricing.
NDC	Specific National Drug Code required to determine the drug's AWP.

Home infusion visits and separately payable suppliesHCPCSCovered

A4221	Home infusion supply code paid separately from the associated visit.
A4222	Home infusion supply code paid separately from the associated visit.
A4223	Home infusion supply code paid separately from the associated visit.
99601	Home infusion visit procedure code associated with separately payable supplies.
99602	Home infusion visit procedure code associated with separately payable supplies.

Temporary national S codes and administrative per diemsHCPCSNot Covered

S codes

Temporary national codes are not recognized by Medicare and are excluded from payment of overall administrative charges or expenses incorporated into home infusion S-code per diems.

Qualifying home infusion drug payment

Payment rate95% of the Average Wholesale Price (AWP)

Applicable drugsQualifying home infusion drugs, including drugs that do not appear on the Medicare ASP file

Pricing information requiredBill with an appropriate HCPCS J code and a specific National Drug Code (NDC); the NDC determines the drug’s AWP

DME-infused drug payment

Payment rateAverage Sales Price (ASP) plus 6%

Applicable drugsDrugs infused through Durable Medical Equipment (DME)

Provider and Billing Responsibilities

Prior Authorization

Preauthorization Required for Home Infusion

Obtain authorization before providing home infusion services. Home infusion services must be preauthorized in accordance with applicable TRICARE requirements.

Documentation Required

Meet TRICARE Policy and Coverage Requirements

Provide home infusion services only in accordance with TRICARE policy and coverage requirements. Services must otherwise be covered and delivered under the applicable TRICARE rules, including requirements governing authorized providers, covered professional services, drugs, and supplies.

Documentation Required

Establish CSP Eligibility

Establish and maintain eligibility for Corporate Services Provider (CSP) status under TPM Chapter 11, Section 12.1 before billing as a corporate services provider.

Key Terms and Reimbursement Concepts

Corporate Services Provider (CSP)

EntityA freestanding corporate entity eligible for Corporate Services Provider status under TPM Chapter 11, Section 12.1

Services supportedCovered home infusion professional services, related drugs, and supplies

Payment identifierPayment is made directly under the corporate entity’s own tax identification number

CMAC

Full nameCHAMPUS Maximum Allowable Charge

Reimbursement methodFee-for-service reimbursement system

Applicable services

Policy Summary

PayerDHA

PolicyProcessing and Payment of Home Infusion Claims

Policy CodePolicy 6010.61-M

Change TypeModified

Effective DateN/A

Next Review DateN/A

Key ActionObtain preauthorization for home infusion services before providing them.

SourceLink

On This Page

Effective dateJanuary 1, 2017

Separate supply payment

Payment treatmentSupplies billed in association with a home infusion visit are paid separately from the associated visit

Supply codesA4221, A4222, and A4223

Associated visit codesCPT 99601 and 99602

Prior Authorization

Follow TPM Preauthorization Requirements

Obtain preauthorization and follow the applicable home infusion requirements in TPM Chapter 8, Section 20.1.

Documentation Required

Use Authorized CSP Professionals

Meet CSP eligibility requirements and ensure professional services are furnished by TRICARE-authorized individual providers employed by or under contract with the freestanding corporate entity.

Billing Rule

Bill Under the Authorized CSP Tax ID

Bill covered professional services, related drugs, and supplies directly under the authorized CSP's own tax identification number. Reimbursement is made to the TRICARE-authorized corporate services provider under the CMAC fee-for-service structure.

Denial Risk

No Additional Facility or Travel Charges

Do not bill additional facility charges that are not already incorporated into the professional service structure. Provider travel expenses are also not covered.

Facility charges included in overhead and malpractice cost indices used to establish locally adjusted CMAC rates are not separately payable.
Additional provider travel expenses are not covered.

Billing Rule

Apply Home Infusion Drug Sourcing and Pricing Rules

Apply the applicable sourcing and pricing rules when the drug is unavailable from the TRICARE Pharmacy (TPharm) or the beneficiary is not required to obtain it from TPharm.

Home infusion drugs are generally priced at 95% of Average Wholesale Price (AWP), including drugs that do not appear on the Medicare Average Sales Price (ASP) file.
Bill the drug with an appropriate HCPCS J code and a specific National Drug Code (NDC) for pricing.
J-3490 may be used for reporting in lieu of a specific HCPCS code when the drug is FDA-approved and has a specific NDC for pricing.

Denial Risk

Review Medicare PR-50 Denials

Review every home infusion claim with Medicare denial code PR-50 to determine whether the denial reflects a Medicare benefit limitation or indicates that the services were not medically necessary.

TRICARE pays as primary when Medicare denied the services because of benefit limitations.
Deny the claim when the Medicare denial is unrelated to a benefit limitation.

Eligible CSP home infusion professional services provided by TRICARE-authorized individual providers

Corporate Services Provider eligibility and payment

Eligibility standardThe corporate entity must meet the CSP eligibility requirements in TPM Chapter 11, Section 12.1

Authorized professionalsServices must be provided by TRICARE-authorized individual providers employed by or under contract with the freestanding corporate entity

Covered paymentPayment may cover professional services, related drugs, and supplies under the CSP’s own tax identification number

TPharm

Full nameTRICARE Pharmacy

Sourcing ruleHome infusion drug pricing under this policy applies when the drug is unavailable from the TPharm or the beneficiary is not required to obtain it from the TPharm

Contract requirementHome infusion drugs provided by the TPharm are subject to the policies and requirements of the TPharm contract

AWP

Full nameAverage Wholesale Price

Policy useUsed to price qualifying home infusion drugs

Applicable payment ruleQualifying home infusion drugs are paid at 95% of AWP

ASP

Full nameAverage Sales Price

DME drug ruleDrugs infused through Durable Medical Equipment are priced at ASP plus 6%

Policy contextASP is used in Medicare-aligned drug reimbursement calculations; qualifying home infusion drugs remain priced at 95% of AWP under this policy