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Insurance Coverage Trends
Third Party Payer |
In-Patient |
Out-Patient |
| Private |
Based on managed care contractual agreement, flat
percentage, or per diem rate. |
Indemnity plans must have a prescription drug
provision in order to provide coverage and
reimbursement. Managed care plans including prescription
drug benefits will allow for coverage and reimbursement
of an FDA-approved drug not otherwise considered
"investigational" in its use. Basic and/or major medical
plans will allow for coverage and reimbursement as
determined by benefit package. Many individual policies
contain restrictions against blood and blood
products. |
| Medicare (Federal) |
Effective October 1, 1997, Medicare Part A allows an
add-on payment for blood clotting factor dispensed to a
hemophilia patient during an in-patient stay.
Current add-on payment rates should be
verified with the local Medicare Fiscal Intermediary.
Revenue Code: 636Billing
Component: Units
100 international units of blood clotting factor
equals one (1) billable unit. When submitting bill round
to nearest hundred: 0-49 down, 50-100 up.
Payment will be made for blood clotting factor only
if there is an ICD-9-CM diagnosis code for hemophilia
and the appropriate HCPCS code included on the
bill. |
Effective January 1, 2005, Medicare Part B
reimbursement is based on the Average Sales Price (ASP)
plus 6%. Blood Clotting Therapies also receive a $0.14
per unit "furnishing fee"
(This information should be verified by local Part B
carrier until HCFA releases written
regulations.) |
| Medicaid (State) |
Many Medicaid programs reimburse hospitals based on
Medicare's DRGs (Diagnostic Related Groups) or a flat
per diem rate. |
Reimbursement varies by state
program. |
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