Physician Administered Drugs and Hospital Specialty Drugs: Policy Clarification and Frequently Asked Questions

Policy Clarification

Physician Administered Drugs

Certain Physician Administered Drugs (PADs) administered in the office or clinic fall under the PAD Prior Authorization (PA) policy. Providers billing for PADs on the CMS 1500 form or 837P should refer to Appendix Y: Physician Administered Drug Medical Benefit Prior Authorization Procedures and Criteria for the list of PADs requiring a PA.

Providers must ensure a PA request is submitted to Acentra Health (previously Kepro) through the Atrezzo provider portal and an approval is received prior to administering the PAD to the member. Visit Colorado Prior Authorization Request Program (ColoradoPAR) web page for additional information, recorded trainings, and user guides.

When submitting a PAD PAR to Acentra, the servicing provider is the billing provider. Ensure the billing provider (typically the clinic/office) is entered on the PA as the servicing provider to successfully submit the PA and to avoid subsequent PAD claims processing issues.

Hospital Specialty Drugs

Approved hospital administered specialty drugs fall under the Hospital Specialty Drug Policy. Providers who bill for PADs on the UB-04 or 837I should refer to Appendix Z: Hospital Specialty Drugs for the list of specialty drugs subject to this policy.

Member-specific PA requests must be submitted directly to the Department using the most up-to-date and applicable request form. The PA request must be approved prior to the administration of the specialty drug. Visit the Physician-Administered Drugs web page for resources, including Appendix Z, coverage standards, request forms, and submission requirements.

Any PA requests inaccurately submitted to and subsequently approved by Acentra will not be valid and the billed claim line will be denied.

General Information

Retroactive requests are not usually considered, and PA approval does not guarantee payment. Both the PAD and IP/OP Hospital benefits require the National Drug Code (NDC) of the PAD administered to the member to be billed on the claim line. Refer to Appendix X: Healthcare Common Procedure Coding System (HCPCS) / NDC Crosswalk for Billing Physician-Administered Drugs for guidance and valid and reimbursable HCPCS/NDC combinations.

Refer to the PAD Billing Manual and the Inpatient/Outpatient (IP/OP) Billing Manual or visit the PAD web page for additional policy information.

Frequently Asked Questions

1. How do I know when to refer to Appendix Y versus Appendix Z?
   1. If you are enrolled as a clinic or practitioner and you bill claims on the CMS 1500 form or 837P:
      1. Appendix Y and the associated prior authorization requirements pertain to you.
   2. If you are enrolled as an inpatient/outpatient hospital and you bill claims on the UB04 or 837I:
      1. Appendix Z and the associated prior authorization requirements do pertain to you.
          
2. How do I know when PADs are added to either Appendix Y or Appendix Z?
   1. Providers are encouraged to sign up for Provider News.
      1. Sign up to receive:
         1. General and specific provider type bulletins, newsletters, and emails with policy updates, changes, implementations, etc.
             
3. I see a HCPCS on both Appendix Y and Appendix Z - is this an error? 
   1. No, this is not an error, as the two appendices apply to different policies.
   2. Refer to the respective appendices for applicable PA policies, requirements, and procedures.
       
4. My claim was denied, what do I do now?
   1. Refer to your EOB for denial reasons and fix any billed issues within your control.
   2. Contact the Provider Call Center for additional information regarding the denial.
   3. Should no resolution be reached after completing the two previous steps, email HCPF_PAD@state.co.us.
       
5. What happens if I do not get an approved PA prior to administration of the PAD for either policy?
   1. The provider must ensure an approved PA is on file prior to the administration of the PAD, as retroactive authorizations are not usually approved.
      1. Few exceptions are considered due to extenuating circumstances.
         1. Should a provider have proof of extenuating circumstances, an email should be sent to HCPF_PharmacyPAD@state.co.us.
            1. Retro PA email should contain: 
               1. All PA request forms and clinical documentation,
               2. A detailed account of what occurred, 
               3. Proof of extenuating circumstances.
         2. Office/clinic employee negligence, employer failure to provide sufficient, well-trained employees or failure to properly monitor the activities of employees and agents (e.g., billing services) are not considered extenuating circumstances beyond the provider's control.
      2. If an approved PA is not on file prior to the treatment of the Colorado Medicaid member, the claim line will be denied.