CSHCN 2008 > Physician > Benefits and Limitations

24.3.18 Blood Factor Products

Blood factor products and related pharmaceuticals are benefits of the CSHCN Services Program with the following diagnosis codes:

Refer to: Section 3.1, "Provider Enrollment," on page 3-2 for more detailed information about CSHCN Services Program provider enrollment procedures.

Reimbursement for blood factor products is the lower of either the billed amount or 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 upon the dose calibration of the product.

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

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 and manufacturer or by National Drug Code (NDC), and the following HCPCS codes must be used:

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

Procedure codes 1-J7193, 1-J7194, and 1-J7195 are limited to diagnosis 2861, Congenital factor IX disorder.

Procedure code 1-J-7187 is limited to the following diagnosis codes:

Procedure code 1-J-7189 is limited to the following diagnosis codes:

If procedure code 1-J7195 is billed on the same day as procedure code 1-J7193 and/or 1-J7194 then 1-J7195 is paid and 1-J7193 and/or 1-J7194 are denied as part of 1-J7195 for the same provider.

If procedure code 1-J7194 is billed on the same day as procedure code 1-J7193 then 1-J7194 is paid and 1-J7193 is denied as part of 1-J7194 for the same provider.

Medical review is required for approval of blood products for any diagnosis other than those listed above and/or for exceptions to any diagnosis restrictions.

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.