Provider News and Updates

Coverage Requirement Changes for Provider-Administered Specialty Infusions

Beginning October 1, 2019, Prominence Health Plan and CDS Group Health now require additional justification for medical necessity for infusion therapies of select drugs performed at outpatient hospital settings. Infusion therapies impacted by this new policy may still be given in other sites of care, such as physician’s offices, ambulatory infusion facilities and home infusion settings. These requirements apply to the Commercial employer group, Medicare Advantage and CDS products offered by Prominence Health Plan and CDS Group Health.

Without specific prior authorization for an outpatient hospital site of care for select infusion therapies listed in the policy, Prominence Health Plan will deny for claims with the following CMS/AMA place of service codes:

  • 19 Off Campus-Outpatient Hospital
  • 22 On Campus-Outpatient Hospital

Access the complete provider policy regarding this change