Site of Care medical necessity reviews for long-acting colony-stimulating factors begin June 1, 2021
Effective with dates of service on or after June 1, 2021, medical necessity review of the site of care is required for the following long-acting colony-stimulating factors for oncology indications for Empire commercial plan members.
- Neulasta® & Neulasta Onpro® (pegfilgrastim)
- Fulphila® (pegfilgrastim-jmdb)
- Udenyca® (pegfilgrastim-cbqv)
- Ziextenzo® (pegfilgrastim-bmez)
- Nyvepria™ (pegfilgrastim-apgf)
The review will be administered by AIM Specialty Health® (AIM).
AIM will evaluate the clinical information in the request to the CG-MED-083 policy, or Site of Care: Specialty Pharmaceuticals, to determine if the hospital-based outpatient setting is medically necessary for the medication administration. To see the policy and what clinical considerations are taken into account for determination, visit Empire’s Medical Policy and Clinical UM Guideline page and type Specialty in the search field. You may contact AIM to request a peer-to-peer discussion before or after the determination.
The site of care medical necessity review only applies to administration performed in an outpatient hospital setting. This does not apply to requests for review of medication administration performed in a non-hospital setting or as part of an inpatient stay. Reviews also do not apply when Empire is the secondary payer.
Submit a request for review
Starting May 16, 2021, ordering providers may submit prior authorization requests for the hospital outpatient site of care for these medications for dates of service on or after June 1, 2021 to AIM in one of the following ways:
- Access AIM ProviderPortalSM directly at providerportal.com. Online access is available 24/7 to process orders in real-time, and is the fastest and most convenient way to request authorization.
- Access AIM via the Availity Web Portal at availity.com
- Call the AIM Contact Center toll-free number: 1- 877-430-2288, Monday–Friday, 8:00 a.m.–6:00 p.m. ET.
Please note, this review does not apply to the following plans: BlueCard®, Federal Employee Program® (FEP®), Medicaid, Medicare Advantage, Medicare Supplemental plans. Providers can view prior authorization requirements for Empire members on the Medical Policy & Clinical UM Guidelines page at empireblue.com/provider.
Providers should continue to verify eligibility and benefits for all members prior to rendering services.
If you have questions, please call the Provider Service phone number on the member’s ID card.
Note: In some plans “level of care” or another term such as “setting” or “place of service” may be the term used in benefit plans, provider contracts or other materials instead of or in addition to “site of care” and in some plans, these terms may be used interchangeably. For simplicity, we will hereafter use “site of care.”
March 2021 Empire Provider News