CurrentHumanaPolicy CP2024007

Self-Administered Drugs While Outpatient in a Hospital

This Humana Medicare Advantage claims payment policy governs billing and reimbursement rules for self-administered drugs and biologicals furnished by a hospital to patients during outpatient hospital encounters; it applies to facility services for Humana Medicare Advantage products.

Policy Summary

PayerHumana

PolicySelf-Administered Drugs While Outpatient in a Hospital

Policy CodePolicy CP2024007

Change TypeNo material change

Effective Date06/2024

Next Review Date

Key ActionReport self-administered drugs on hospital institutional claims using revenue code 0637 and HCPCS code A9270; Humana does not reimburse these under MA basic benefits.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

A9270HCPCS code for noncovered item/service (self-administered drugs)

0637Revenue code to report self-administered drugs in outpatient hospital claims

Medicare AdvantageProduct type this policy applies to

06/2024Published date

Coverage stance

Humana MA facility services coverage stance for self-administered drugs in outpatient hospital settings:

Humana does not reimburse, under Medicare Advantage (MA) basic benefits, for self-administered drugs that are given in the outpatient hospital setting in the applicable jurisdiction.

Self-administered drugs given in an outpatient hospital setting should be reported on hospital institutional claims using revenue code 0637 and Healthcare Common Procedure Coding System (HCPCS) code A9270.

Drugs and biologicals given in an outpatient hospital setting that are NOT self-administered should be reported using the combination of the applicable revenue code and applicable CPT or HCPCS code.

Claims payments remain subject to requirements of medical necessity, reasonableness, and applicable referral or authorization requirements.

Policy Summary

PayerHumana

PolicySelf-Administered Drugs While Outpatient in a Hospital

Policy CodePolicy CP2024007

Change TypeNo material change

Effective Date06/2024

Next Review Date

Key ActionReport self-administered drugs on hospital institutional claims using revenue code 0637 and HCPCS code A9270; Humana does not reimburse these under MA basic benefits.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Billing, reimbursement, and coordination actions for providers

Billing Rule

Billing and reimbursement rules

Self-administered drugs given in an outpatient hospital setting should be reported on hospital institutional claims using revenue code 0637 and HCPCS code A9270. Drugs and biologicals that are not self-administered should be reported using the applicable outpatient hospital revenue code with the appropriate CPT or HCPCS code. Claims payments remain subject to medical necessity, reasonableness, and any applicable referral or prior authorization requirements.

Revenue code 0637 and HCPCS A9270 required for self-administered drugs in outpatient hospital setting
Non–self-administered drugs: report with applicable revenue code + CPT/HCPCS
Payments subject to medical necessity, reasonableness, and authorization/referral rules

Denial Risk

Claims processing caveats

Claims processing and payments are subject to the plan's medical necessity and reasonableness criteria and any applicable referral or authorization requirements. Providers should ensure required clinical documentation and prior authorizations (when applicable) are included with claims to avoid denials or delays.

Ensure clinical documentation supports medical necessity
Verify and obtain prior authorization when required

Note

Part D coordination

A Humana Medicare Advantage member who has Medicare Part D prescription drug coverage may be entitled to coverage of self-administered drugs through their Part D benefit carrier. Enrollees may request coverage or reimbursement from their Part D plan for self-administered drugs provided in the outpatient hospital setting.

Advise members with Part D to contact their Part D benefit carrier for coverage or reimbursement
Providers may assist members in coordinating benefits with the Part D plan

Codes and terms

HCPCS code A9270 — Noncovered item or service

HCPCS code A9270Noncovered item or service

Revenue code 0637 — Revenue code identifying self-administered drugs

Revenue code 0637Identifies self-administered drugs for hospital outpatient reporting

Self-administered drugs — Definition

DefinitionDrugs and biologicals excluded, in a jurisdiction, from Original Medicare Part B coverage because the jurisdiction's A/B MAC has determined they are usually self‑administered by patients

A/B MAC listsEach A/B MAC publishes a list of drugs and biologicals it has identified as self‑administered drugs

ScopeApplies to drugs/biologicals identified by the jurisdictional A/B MAC for exclusion from Part B coverage

OpenPayer

Self-Administered Drugs While Outpatient in a Hospital

Coverage stance

Reporting codes

Billing, reimbursement, and coordination actions for providers

Codes and terms

A9270	Noncovered item or service (self-administered drugs)
0637	Revenue code for self-administered drugs (hospital outpatient)