Additional Important Claim Information
If required claim information is not submitted, a claim will deny as unprocessable. When a code denies as unprocessable, correct the claim error and resubmit a new claim.
If a claim denies due to the number of units exceeding acceptable maximum (e.g. N362), verify MUEs and number of allowable units. MUEs denied have appeal rights. Medical documentation must support services rendered.
Date of Service
If the Factor IIX is administered within a facility or "incident to" a physician service, enter the actual date the drug was administered as the DOS. If the Factor IIX is being billed by a pharmacy to replenish the patient's home supply, enter the date of delivery as the claim DOS.
The amount of clotting factors determined to be necessary to have on hand and thus covered under this provision is based on the historical utilization pattern or profile developed by the carrier for each patient. Changes in a patient's medical needs over a period of time may require adjustments in the profile. It is expected that the treating source, e.g., a family physician or Comprehensive Hemophilia Diagnostic and Treatment Center, will have such information.
For hemophilia factors, we would expect:
- Diagnosis on a claim must be one of the hemophilia diagnosis codes
- Provider's prescription must include:
- Name of drug
- Concentration (if applicable)
- Dosage to include initiation date, frequency of administration, duration of infusion (if applicable), signature, date and any other individual state requirements
- Record from physician's office must include evidence of medical necessity
- Copy of this medical record must be provided on request