As we announced in previous issues of Network Matters, effective for dates of service beginning Feb. 26, 2018, Harvard Pilgrim will apply industry standard claims edits and will not reimburse for drug dosages above limits in accordance with FDA-approved labeling, accepted compendia, and/or evidence-based practice guidelines for the medical drugs listed here for our commercial members.
A more detailed list that includes the maximum dosages is also available in HPHConnect, Harvard Pilgrim’s secure web-based transaction tool; you’ll find that list in the “Office Management” section of HPHConnect. If you are currently not a user of HPHConnect, it’s quick and easy to register online.
Dosages in Accordance with FDA & Other Compendia
Under our new Drug Dosage and Frequency Medical Policy, the drug dosage, frequency and route of administration should be supported by one or more of the following for the treatment indication:
- U.S. Food and Drug Administration prescribing information
- National Comprehensive Cancer Network Drug & Biologics Compendium
- American Hospital Formulary Service Drug Information
- DRUGDEX System
Harvard Pilgrim reserves the right to conduct post-payment review and audit of claims submitted for drugs and may recover payments made for amounts in excess of the FDA labelling.
Billing for Multiple Dates of Service
On a related note, when billing a professional claim with more than one date of service on a paper CMS-1500 form, or electronically via an 837P, please bill each date of service on its own line — along with the procedure code and number of units for that individual day. For example, instead of billing with the date range of 6/29/2017 – 6/30/2017 and 12 units on one line, it would be more appropriate to bill 6/29/2017 and 6 units on one line, and 6/30/2017 and 6 units on the next line. Harvard Pilgrim is updating our systems related to the maximum dosage policy, and as of March 1, 2018, providers who bill professional claims with a date range may experience claims processing issues resulting in partial reimbursement.
For more information, please refer to the: