Here’s what you need to know about billing and requesting prior authorization for denosumab

Part B specialty drugs Prolia^® and Xgeva^® have the same generic name (denosumab) and HCPCS code (J0897). Both drugs require authorization for Medicare Plus Blue℠ and BCN Advantage℠ members when administered by a health care provider in outpatient facilities or physicians’ offices.

Here’s some important information about billing and requesting prior authorization for denosumab drugs.

Include the NDC when billing for these drugs

To ensure appropriate and timely reimbursement of claims, be sure to enter the following National Drug Code numbers along with HCPCS code J0897:

• Prolia — Enter NDC 55513071001
• Xgeva — Enter NDC 55513073001

We can reimburse claims submitted for these drugs more quickly when you:

• Include the NDC along with the HCPCS code.
• Have an approved prior authorization request on file.

Submitting prior authorization requests

To submit prior authorization requests for these drugs, log in to our provider portal (availity.com**). Click on Payer Spaces and then on the Blue Cross and BCN logo. On the Applications tab, do the following:

• For Prolia, which is used to treat osteoporosis, scroll down and find the links to the NovoLogix^® tools. Click the appropriate link.
• For Xgeva, which is primarily used to treat bone metastases due to solid tumors, click the AIM Provider Portal link.

Reminders:

• Prolia and Xgeva are part of members’ medical benefits, not their pharmacy benefits.
• Authorization isn't a guarantee of payment. Health care practitioners need to verify eligibility and benefits for members.

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