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Elizabeth M. Whitehorn, Director

Provider Notice issued 09/23/14

 Fee-for-Service Billing of Synagis

To:​ Enrolled Hospitals: Chief Executive Officers, Chief Financial Officers, and Patient Accounts Managers; Physicians; Advanced Practice Nurses (APNs); Local Health Departments; and Pharmacies​
​Date: ​September 23, 2014
​Re:  Fee-for-Service Billing of Synagis​

 

The purpose of this notice is to clarify the department’s billing protocol for the injectable drug Synagis.

Per policy initiated with the June 2, 2005 Informational Notice titled, Changes in Policy for Injectable Drugs (pdf), the department does not reimburse practitioners for the injectable drug Synagis.

Beginning with the 2014-2015 respiratory syncytial virus (RSV) season (November 1, 2014 through March 31, 2015), hospitals may no longer bill fee-for-service for Synagis. Only enrolled pharmacies are allowed to submit claims in accordance with the Synagis criteria through the pharmacy point-of-sale system.

The Handbook for Practitioners Rendering Medical Services, Topic A-202.13, Allowable Fee-for-Service Charges by Hospitals, will be revised to remove Synagis as a billable item.

Note: The billing instructions in this notice apply to patients enrolled in traditional fee-for-service, Accountable Care Entities (ACEs), and Care Coordination Entities (CCEs), and do not apply to patients enrolled in Managed Care Organizations (MCOs) and Managed Care Community Networks (MCCNs).

It is imperative that providers check HFS electronic eligibility systems regularly to determine beneficiaries’ enrollment in a plan. The Recipient Eligibility Verification (REV) System, the Automated Voice Response System (AVRS) at 1-800-842-1461, and the Medical Electronic Data Interchange (MEDI) system will identify any care coordination plan in which the beneficiary is enrolled. Plan contact information for questions related to coverage and billing requirements, as well as information regarding the way each plan is displayed in the department’s electronic eligibility systems may be located in the June 24, 2014 informational notice titled, Revised - Care Coordination Enrollment for Children, Families and ACA Adults

Any questions regarding this notice may be directed to the Bureau of Professional and Ancillary Services at 1-877-782-5565.

 

Theresa A. Eagleson, Administrator

Division of Medical Programs