QUEST Integration – Home IV Therapy – Per Diem Payment Method

Original Effective Date:

04/01/1999

Current Effective Date:

01/01/2015

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

The per diem allowance is a daily payment that includes (but is not limited to) nursing services, pharmacy consultations, nutritional/dietary services, catheter care, dressing maintenance, waste disposal, pumps, IV pole rental, compounding and dispensing of medication, informational materials, patient and family training, delivery of drugs and supplies, and other ancillary services and supplies as required.

Exceptions

Nursing Care during Extended Therapy

If the member is receiving extended therapy and requires a non-routine nursing care visit (e.g., infiltrated IV), benefits for the nursing care visit must be precertified by HMSA. Nursing care during the extended period for routine maintenance (e.g., dressing changes, blood draws, catheter flushing) is included in the per diem for extended care and will not be paid separately.

Inclusive Services

The following are part of the per diem payment and are not paid separately:

• Supplies

  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, informational materials, syringes, tubing, filters, heparin, normal saline, alcohol swabs, catheters, care kits and dressings.

• Routine maintenance

  Catheter care (including flushing) and routine dressing changes are also included in the per diem charge for a patient receiving active therapy. 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.

General Payment Criteria

• 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) in this section.
• 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, please precertify the larger supply, 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 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 Refunding HMSA) in the general information section.

Billing for Multiple Therapies:

Application

When a second or subsequent drug is added to the patient’s previously established treatment regimen, the patient will remain at his or her current level of treatment and will not revert to an initial level. If the patient is in the extended therapy period, no reduction will be made to the allowed per diem for the therapy.

Example

If the patient has been taking cefazolin, intravenously, for 10 days, he or she is in the continued level of treatment. The administration of gentamicin introduced on day 11 would be paid based on the per diem code for antibiotic therapy at the continued treatment level. Modifier code SH would be appended to the per diem code for the second therapy.

Revision History