Physician-administered drugs covered under Gold Coast Health Plan Total Care Advantage Medicare (HMO D-SNP) Part B benefit include certain infusions, injectables or other specialty medications billed by a provider on a medical claim using a procedure code (e.g., J-code, C-code, Q-code). These drugs are generally given in a physician’s office, clinic, infusion center or hospital outpatient setting.
For Medicare Part B, some of these medications require prior authorization before they can be administered. Providers must submit a prior authorization request with clinical documentation that supports medical necessity, such as diagnosis, treatment history and dosing details. Once submitted, GCHP will review the request and issue an organization determination within the required Centers for Medicare and Medicaid Services (CMS) timeframe (72-hours for standard requests; 24-hours for expedited requests).
It is important to note – per CMS, a request is deemed as requiring expedited review only if the standard 72-hour timeframe for a decision could jeopardize the life, health or the member’s ability to regain maximum function.
To avoid delays or denials, providers should submit a completed prior authorization request with all necessary clinical documentation. Prior authorizations may be submitted either electronically via the Provider Portal (recommended) or by completing a Prior Authorization Treatment Request Form. Claims may be delayed or denied until the required information is received to establish medical necessity.
For a list of Medicare Part B drugs requiring prior authorization, please see the Total Care Advantage Medicare Part B Drug List. This list is updated quarterly in alignment with guidance and direction received by CMS and the GCHP Pharmacy and Therapeutics (P&T) Committee.