CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Medicaid Medical Benefit Only Policy

Identifies medications that are covered only through the member's medical benefit for administration in a clinician's office, outpatient setting, or by a home infusion therapy provider; applies to Medicaid members and providers.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyMedicaid Medical Benefit Only Policy

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJan 1, 2020

Next Review DateN/A

Key ActionObtain prior authorization when required and bill these products through the member's medical benefit for administration in an appropriate clinical setting.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

25+listed provider‑administered medications or product groups

60 daysadvance notification period

Medicaidapplicable program

1/2020policy effective date

Coverage criteria for provider‑administered medications

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyMedicaid Medical Benefit Only Policy

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJan 1, 2020

Next Review DateN/A

Key ActionObtain prior authorization when required and bill these products through the member's medical benefit for administration in an appropriate clinical setting.

SourceLink

On This Page

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Provider obligations and prior authorization

Prior Authorization

Prior Authorization & Medical-Benefit Billing

Products listed in this policy are covered only through the Medical Benefit and may require prior authorization. Ensure requests for administration in a clinician's office, outpatient setting, or via home infusion are submitted under the medical benefit. If a medical-administered medication is billed through the pharmacy benefit, claims may be denied and should be rebilled to the medical benefit.

Medical benefit exclusivity: medications listed in this policy are available exclusively on the Medical Benefit.
Prior authorization may be required — confirm and obtain authorization prior to administration if applicable.

Documentation Required

Provider billing & documentation actions

Providers must verify benefit coverage and obtain any required prior authorization before administering these products. Document medical necessity, route of administration, and site of service on the claim. If a product is administered but not billed via the medical benefit, the claim may be denied and the provider will need to reprocess under the correct benefit.

Document: indication, dose, administration date, and place of service on all claims.
If claim originally billed to pharmacy benefit, rebill under medical benefit to avoid denial.

Note

Member notification requirement

Members and providers will receive a 60-day advance notification if a medication's benefit coverage changes and the member received the medication under the pharmacy benefit in the prior 180 days. Providers should counsel members about potential upcoming benefit changes and coordinate transition of care as needed.

Member notification: 60-day advance notice when benefit changes and member obtained medication under pharmacy benefit within previous 180 days.
Coordinate transitions if a medication moves to the medical benefit to avoid gaps in therapy.

Billing Rule

Medical benefit exclusivity & billing guidance

The medications listed in this policy are available exclusively on the Medical Benefit for administration in a clinician's office, outpatient setting, or by a home infusion provider. Examples include IV infliximab products, immune globulins, provider-administered contraceptives, hemophilia factor products, and others listed in the policy. Verify correct benefit and billing pathway prior to administration to prevent claim denials.

Exclusive Medical Benefit list includes (not limited to): IV infliximab products; immune globulin agents (IV and SC); provider-administered contraceptives (IUDs, implants); Krystexxa; Cinqair; Xiaflex; long-acting G-CSFs (e.g., Neulasta and biosimilars); Givlaari; Tysabri; Ocrevus; Rituxan and biosimilars; hemophilia products (Feiba, Novoseven RT, Sevenfact, Coagadex, Corifact, Tretten).
If a product on this list is billed through the pharmacy benefit, contact payer to correct billing to the medical benefit to avoid denial.

Policy background

This policy lists specific provider‑administered medications that are covered under the Medicaid Medical Benefit rather than the pharmacy benefit. The policy designates that these products are covered only when administered in an appropriate clinical setting (for example, a clinician's office, outpatient setting, or by a home infusion therapy provider) and enumerates included product groups such as intravenous infliximab products, immune globulin agents (IV and SC), long‑acting granulocyte colony stimulating factors, provider‑administered contraceptives and implants, hemophilia factor products, various specialty infusions (e.g., Krystexxa, Cinqair, Xiaflex, Tysabri, Ocrevus), and specific named products including Rituxan (rituximab) and its biosimilars.

OpenPayer

Medicaid Medical Benefit Only Policy

Coverage criteria for provider‑administered medications

Billing, codes, and pharmacy-to-medical lookback

Provider obligations and prior authorization

Policy background

Key definitions

Site‑of‑care requirements

Biosimilar inclusions