Here are updated guidelines for billing self-administered medications provided in outpatient facilities

When a Medicare Advantage member is receiving services in an outpatient facility but hasn’t brought their self-administered medications with them, here are some guidelines for what to do and what not to do.

These guidelines include and expand on information we provided in earlier communications.

What to do

Here are steps to follow:

1. Obtain the medication through the onsite ambulatory pharmacy, not from the inpatient pharmacy.
2. Administer it to the member.
3. Have the onsite ambulatory pharmacy do the following:
• Deliver the medication to the patient’s bedside.
• Bill for the medication under the member’s Medicare Part D pharmacy benefits.

The member is responsible for the copayment amount.

What not to do

We ask that you avoid obtaining the medication through the inpatient pharmacy and billing for the medication on the facility bill under Medicare Part B. Here’s why: When outpatient facilities administer and bill self-administered medications through Medicare Part B, the claims will be denied as not payable. The member has to seek direct reimbursement for the expenses they incur during the outpatient stay.

Questions and answers

Here are the answers to some questions we received following an earlier communication on this topic.

Which drugs are considered self-administered?

The Centers for Medicare & Medicaid Services, not Blue Cross or BCN, determines which drugs are self-administered. Refer to CMS’ Self-Administered Drug Exclusion List (SAD List).**

Can outpatient facilities bill the self-administered drug on the facility bill?

• If the outpatient facility has an onsite ambulatory pharmacy, that pharmacy should bring the drug to the bedside and bill it to the member’s Part D benefits. The member pays the copayment.
• If the outpatient facility doesn’t have an onsite ambulatory pharmacy, the facility should obtain the drug from the inpatient pharmacy and bill it using revenue code 0637 (self-administered drugs). This claim will be denied for beneficiary responsibility under the member’s Part B medical benefits and the provider can bill the member for the item on that line. The member can use the bill they receive to seek reimbursement directly through their Part D plan.

Do Medicare Plus Blue℠ and BCN Advantage℠ handle facility claims submitted with revenue code 0637 differently?

Both Medicare Plus Blue and BCN Advantage handle these claims the same way:

• Medicare Plus Blue denies facility claims submitted with revenue code 0637 under the member’s Part B medical benefits. The member should seek reimbursement under their Part D benefits.
• Earlier this year, BCN Advantage updated its claims system to deny the service billed with revenue code 0637 and tell the member: “This service is not a payable Part B benefit; please consult your Part D benefits to seek any reimbursements. The patient is responsible.”

Which members the information in this article applies to

This information applies to our Medicare Advantage (Medicare Plus Blue and BCN Advantage) members during their outpatient stays. It doesn’t apply to Blue Cross Blue Shield of Michigan and Blue Care Network commercial members.

**Blue Cross Blue Shield of Michigan and Blue Care Network don’t own or control this website.