Use correct HCPCS code for Spravato

The Centers for Medicare & Medicaid Services established the permanent HCPCS code of S0013 for Spravato^®, a medical benefit drug, to be used for dates of service on or after Jan. 1, 2021. However, many health care providers are using the older codes for these newer dates of service. This has resulted in problems with reimbursing claims.

We first communicated about this in the article titled “HCPCS replacement codes established,” in the March 2021 issue of The Record.

Prior authorization information
Providers must request prior authorization for Spravato when it’s administered in outpatient settings for:

• Members covered through Blue Cross Blue Shield of Michigan commercial fully insured groups except for groups that have opted out of the prior authorization program. Note: For groups that have opted out of the prior authorization program, Spravato is covered for the FDA‑approved indications.
• Blue Cross commercial members with individual coverage
• Medicare Plus Blue℠ members
• Blue Care Network commercial members
• BCN Advantage℠ members

Additional information
For more information on requirements related to drugs covered under the medical benefit, see the following documents:

• For commercial members, see the Blue Cross and BCN utilization management medical drug list for Blue Cross PPO (commercial) and BCN HMO (commercial) members document.
• For Medicare Advantage members, see the Medical Drug and Step Therapy Prior Authorization List for Medicare Plus Blue PPO and BCN Advantage members document.