Per Diem Payment Method – IV Therapy Index

HMSA payment for home IV therapy is based on a per diem methodology and the drug administered.

Inclusive Services

HMSA’s per diem allowance includes (but is not limited to) pharmacy consultations, nutritional/dietary services, routine flushing of the catheter, waste disposal, compounding and dispensing of medication, informational materials, patient and family training, delivery of drugs and supplies, and other ancillary services and supplies as required.

All supplies necessary to provide home IV therapy services are included in the per diem rate. These supplies may include (but are not limited to) pumps, IV pole rental, syringes, tubing, filters, heparin, normal saline, alcohol swabs, catheters, care kits and dressings.

Excluded Services

In situations where an SNF contracts with a pharmacy to provide medication to their SNF patients where the drugs are NOT included / EXCLUDED from the SNF per diem (e.g., IV medication etc.), these drugs are billed based on the agreement between the SNF and the pharmacy, and either the SNF or the pharmacy will bill HMSA for the drugs EXCLUDED from the SNF per diem for PB members, and HMSA will make payment to the provider who billed for the services.

Nursing Care

Nursing services (CPT codes 99601 and 99602) are covered and do not require precertification. Nursing services may be billed separately and are not included in the per diem for IV therapy.

General Payment Criteria

• Should the physician wish to leave the catheter in place for a future therapy, the physician is responsible for ensuring the patency of the line. HMSA will not cover line maintenance without active therapy.
• Home IV infusion therapy, as well as injectables, must follow FDA guidelines for indications and duration or must meet the criteria in HMSA’s off-label drug use policy (refer to Off-Label Drug Use). If HMSA has a policy for a specific drug, that policy will take precedence over the Off-Label Drug Use policy
• When a patient is unable to tolerate a specific drug due to an allergic or other adverse reaction, or when the patient must be hospitalized before completing a course of home IV therapy, payment for the dispensed drug will be limited to payment for up to a seven-day supply of the drug.
• For subcutaneous and intramuscular injectables dispensed for self-administration by the patient, HMSA will cover the days’ supply ordered by the patient’s physician up to a 30-day supply. If the member requires a larger supply of medication due to vacation, the larger supply should be precertified, prior to dispensing. If a larger supply is dispensed, and the member becomes ineligible during the extended period, HMSA will only pay benefits for the period the member had coverage.
• When a patient receiving enteral therapy is unable to tolerate a specific enteral nutrition formula, or when the patient must be hospitalized before finishing the dispensed formula, payment will be made for up to a 30-day supply of the enteral nutrition formula.
• Do not file claims to HMSA in advance of rendering services. Claims must include only those services that have been rendered. (For subcutaneous and intramuscular drugs dispensed to the patient for self-administration, billing may be done on the day the drug is dispensed.)
• An extension request must be submitted when specific therapeutic treatment duration guidelines will be exceeded.
• If services provided beyond the standard duration have not been approved by HMSA, the participating provider will assume any payment reduction and may not bill the member.
• Payment will not be made for the per diem billed for any day the patient is confined in a hospital or skilled nursing facility as an inpatient.
• HMSA reserves the right to recover any overpayment made due to a provider billing error or to an HMSA error in paying for services that do not meet benefit criteria. (See Reimbursing HMSA.)

Billing for Multiple Therapies

When a member requires multiple therapies (e.g., enteral nutrition and anti-infective) or administration of multiple drugs within a single therapeutic category, the provider may bill an additional per diem charge using modifier codes SH and SJ.

Example – Different therapeutic categories

A patient with end-stage AIDS might begin receiving multiple therapies upon discharge from the hospital. Such a patient might receive enteral therapy, anti-infective therapy, and pain management therapy. Modifier SH would be appended to the per diem for the second therapy, and modifier SJ would be appended to the per diem for the third therapy.

Example – Same therapeutic category

The patient has been taking cefazolin, intravenously. With the addition of gentamicin for anti-infective therapy would be paid. Modifier code SH would be appended to the per diem code for the second therapy.

Benefit application

Benefit levels for home IV therapy and injectables under HMSA plan certificates vary. Some plans may include deductibles and maximums. After the per diem payment is determined, plan benefits (e.g., 80 percent) and deductibles or maximums will be applied.

Example

Suppose a patient is receiving two drugs within a single therapeutic category. If the per diem payment for the first drug administered for a specific therapy is $96.00, and the per diem payment for the second drug administered is $24.00. We will also assume that the eligible charge for each drug is $45. These charges add up to a total eligible charge of $210.00.

When plan benefits are applied (e.g., 80 percent), a payment of $168.00 would be made to the participating provider if applicable deductibles have been met.

Revision History