CSHCN Services Program 2010 > Physician > Benefits, Limitations, and Authorization Requirements

30.2.8 Blood Factor Products

Blood factor products are benefits of the CSHCN Services Program.

Blood factor products require authorization. The physician's prescription must accompany the CSHCN Services Program Authorization Request for Hemophilia Blood Factor Products form.

Refer to: Appendix B, "CSHCN Services Program Authorization Request for Hemophilia Blood Factor Products".

When obtaining authorization or submitting claims, products must be identified by product name, manufacturer, National Drug Code (NDC), and the following procedure codes must be used:

Procedure codes J7186 and J7187 are a benefit with diagnosis codes 2860 and 2864.

Procedure code J7189 is a benefit with diagnosis codes 2860, 2861, 2863, 2869, and V8302.

Procedure codes J1680, J7185, J7190, J7191, J7192, J7198, and J7199 are benefits with diagnosis codes 2860, 2861, 2862, 2863, and 2865.

Procedure codes J7193, J7194, and J7195 are benefits with diagnosis code 2861.

The following table lists the descriptions for the above mentioned diagnosis codes:

Whether provided in a hospital outpatient facility, a physician's office, or the client's home, all ancillary services such as infusion supplies, administration, and home delivery expenses are included in reimbursement for the procedure codes in the table above.

If procedure code J7195 is billed by the same provider on the same date of service as procedure code J7193 or J7194, procedure code J7195 may be reimbursed and procedure code J7193 or J7194 is denied as part of procedure code J7195.

If procedure code J7194 is billed by the same provider with the same date of service as procedure code J7193, procedure code J7194 may be reimbursed and procedure code J7193 is denied as part of procedure code J7194.

Medical review is required for approval of blood factor products for any diagnosis other than those listed above. Exceptions to any diagnosis restrictions will be considered in a medical review, which automatically occurs when the authorization form is submitted with a diagnosis that falls outside of these parameters.

To submit claims for more than 999 dispensed units, enter a quantity of 1 and indicate the specific number of units provided on the claim form.

Reimbursement for blood factor products is the lesser of either the billed amount or an amount derived by a formula using the U.S. Public Health Service price in effect on the date of service plus a dispensing fee of $0.04 per unit or per microgram, depending on the dose calibration of the product.