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Oncology Payment Policy

The following payment policy applies to Tufts Medicare Preferred HMO contracted providers who render professional services in an outpatient or office setting. Note: Audit and disclaimer information is located at the end of this document.

Policy

Tufts Health Plan reimburses medically necessary oncology services.

Definition

Oncology is a field of medicine that deals with the study and treatment of cancer. Chemotherapy is the treatment of cancer with drugs.

General Benefit Information 1

Member eligibility can be verified electronically and detailed benefit coverage may be verified by contacting Tufts Health Plan Medicare Preferred Provider Relations. Tufts Medicare Preferred HMO follows Medicare coverage guidelines. Tufts Health Plan cannot cover items and services not covered under the CMS-approved Tufts Medicare Preferred HMO benefit plan. Tufts Medicare Preferred HMO's benefit plan currently covers a limited number of non-Medicare covered items as supplemental benefits. Note: Supplemental benefits are subject to change each year.

Member Responsibility

Copayments, deductible and/or coinsurance may apply depending upon the member's benefit plan specifics. Tufts Health Plan recommends not billing the member for the coinsurance and/or deductible amount until the claim has processed so that the appropriate member responsibility can be determined. Both the provider's Statement of Account (SOA) and the Electronic Remittance Advice (ERA) will reflect the member's responsibility amount.

Authorization Requirements

Reference the Authorization Policy for specific referral and authorization requirements. Some procedures may require prior authorization with the Tufts Health Plan Precertification Department. Reference the Tufts Medicare Preferred HMO Prior Authorization List for a list of procedures, services and items requiring prior authorization for Tufts Medicare Preferred HMO Members. Tufts Health Plan Medicare Preferred members are encouraged to use CuraScript Pharmacy to obtain oral oncology medications, but are not required to do so. Tufts Medicare Preferred HMO members are allowed to use any contracting network pharmacy for oral oncology medications. If an oncology medication requires prior authorization, complete the Universal Pharmacy Medical Review Request Form and fax it to the Precertification Department at 617-972-9409. Reference the Pharmacy section of our website for additional information. For a complete description of Tufts Medicare Preferred HMO's authorization and notification requirements, reference the Authorization section of the Tufts Medicare Preferred HMO Provider Manual.

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Eligibility is subject to retroactive reporting of disenrollment.

Originated 03/2007, Revised 05/2011

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Tufts Medicare Preferred HMO Oncology Payment Policy

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Billing Information

Submit the most updated industry standard codes. Submit the appropriate ICD-9 diagnosis code carried out to the highest level of specificity. Submit a modifier when appropriate, with the corresponding CPT and/or HCPCS procedure code (s). Submit original claims only once; additional submissions of the same claim will result in a duplicate denial. Reference Avoiding Administrative Claim Denials for additional information. Submit unlisted HCPCS or CPT procedure code(s) on a paper claim form with supporting documentation detailing what services were provided.

Note: Annually and quarterly, HIPAA medical code sets 2 and modifiers undergo revision by CMS, AMA and CCI. Revisions typically include adding, deleting or redefining the description or nomenclature of new HCPCS, CPT procedure and ICD-9 diagnosis codes. As these revisions are made public, Tufts Health Plan will update its system to reflect these changes. EDI Claim Submitter Information · Submit claims in HIPAA-compliant 837P format for professional services. Claims billed with nonstandard codes will reject if billed electronically. Paper Claim Submitter Information · Submit claims on a CMS-1500 form for professional services. Claim line(s) billed with non-standard codes will deny. Chemotherapy Drugs Reference the chemotherapy drug listing for a list of chemotherapy drugs that are accepted by Tufts Health Plan. Chemotherapy CPT Procedure Codes The following table lists chemotherapy CPT procedure codes that are accepted by Tufts Health Plan. The absence or presence of a CPT procedure code is not an indication and/or guarantee of coverage and/or reimbursement. Procedure Description Codes 96360 Intravenous infusion, hydration; initial, 31 minutes to 1 hour 96361 Intravenous infusion, hydration; each additional hour 96365 Intravenous infusion, for therapy, prophylaxis, or diagnosis 96366 Intravenous infusion, for therapy, prophylaxis, or diagnosis Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or 96367 drug); additional sequential infusion, up to 1 hour Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or 96368 drug); concurrent infusion Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); 96372 subcutaneous or intramuscular Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); intra96373 arterial Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); 96374 intravenous push, single or initial substance/drug 96375 Therapeutic, prophylactic, or diagnostic injection (specify substance or drug) Unlisted therapeutic, prophylactic, or diagnostic intravenous or intra-arterial injection 96379 or infusion 96401 Chemotherapy admin, non-hormonal anti-neoplastic

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HIPAA medical code sets include HCPCS, CPT Procedure and ICD-9/ICD-10 diagnosis codes.

Originated 03/2007, Revised 05/20011

Page 2 of 4 Tufts Medicare Preferred HMO Oncology Payment Policy

96402 96409 96411 96413 96415 96416 96417 96521 96522 96523

Chemotherapy admin, hormonal anti-neoplastic Chemotherapy admin, IV push, single Chemotherapy admin, IV push, each additional drug Chemotherapy admin, IV infusion, up to 1 hour Chemotherapy admin, IV infusion, each additional hour Chemotherapy admin, initiation of prolonged chemo infusion (more than 8 hours) Chemotherapy admin, each additional sequential infusion, up to 1 hour Refilling and maintenance of portable pump Refilling and maintenance of implantable pump Irrigation of implanted venous access device for drug delivery systems

Reimbursement Information

Providers are reimbursed according to the Tufts Health Plan Medicare preferred contracted rate regardless of where the service is rendered. Oncology services are reimbursed according to the terms of the provider's contract. Claims are subject to payment edits that are updated at regular intervals and generally based on CMS, Specialty Society Guidelines, and the National Correct Coding Initiative (CCI). Chemotherapy Administration In accordance with the National Correct Coding Edits, chemotherapy administration is included in the vascular access procedures, and injection procedures and not separately reimbursed. Reference CCI and the AMA CPT Manual for additional information. Certain IV injections, refilling and maintenance of portable or implantable pumps or regional hypothermia is included in the IV chemotherapy administration and not separately reimbursed. Reference CCI for additional information. Tufts Health Plan will not reimburse chemotherapy administration (96401-96409) when billed with an evaluation and management (E&M) service as the chemotherapy administration is included in the E&M service. Reference CCI additional information. Tufts Health Plan will not reimburse the irrigation of implanted venous access device for drug delivery systems when billed with chemotherapy administration, intravenous infusion technique, as the irrigation of implanted venous access device for drug delivery systems is included in chemotherapy administration. Reference CCI for additional information. Intravenous Infusion with Chemotherapy Services Intravenous infusion services are included in intravenous chemotherapy services when administered at the same session unless a separately identifiable service is documented. Reference CCI for additional information. Non-Reimbursable Procedure Codes CMS considers some procedure codes non-reimbursable. To better align with CMS, Tufts Health Plan Medicare Preferred may apply non-reimbursable logic to certain procedure codes based on CMS guidelines. In addition, procedure codes may be placed on non-reimbursable logic based on Tufts Health Plan Medicare Preferred policy. Reference your current contract for details regarding non-reimbursable logic.

Originated 03/2007, Revised 05/20011

Page 3 of 4 Tufts Medicare Preferred HMO Oncology Payment Policy

Statement of Account (SOA) The SOA is sent to all providers to provide information on the status of the claim(s) submitted to Tufts Health Plan Medicare Preferred. The SOA indicates status of claims payments, denials and pending claims. If the procedure code(s) submitted is not used in processing, the SOA will reflect the actual procedure code(s) utilized by Tufts Health Plan Medicare Preferred to process the claim. Electronic Remittance Advice (ERA) The HIPAA-compliant 835 ERA is an EDI transaction that providers may request to electronically post paid and denied claims information to their accounts receivable system. When an industry-standard code(s) is submitted and accepted by Tufts Health Plan Medicare Preferred, the electronic remittance advice will reflect the code(s) submitted and the actual procedure code(s) utilized by Tufts Health Plan Medicare Preferred for claims processing.

Document History

March 2007: New Payment Policy April 2008: Clarified that Tufts Health Plan will not reimburse chemotherapy administration when billed with an E&M service. January 2009: Deleted CPT Procedure codes: 90760, 90761, 90765, 90766, 90767, 90768, 90772, 90773, 90774, 90775, & 90779 and replaced with 96360, 96361, 96365, 96366, 96367, 96368, 96372, 96373, 96374, 96375, & 96379. March 2009: Moved Tufts Medicare Preferred information to its own document. January 2010: Removed references to the Tufts Medicare Preferred PPO product. May 2011: Reviewed document for clarify; no content changes made.

Audit and Disclaimer Information

Tufts Health Plan reserves the right to conduct audits on any provider and/or facility to ensure compliance with the guidelines stated in this payment policy. If such an audit determines that your office/facility did not comply with this payment policy, Tufts Health Plan will expect your office/facility to refund all payments related to non-compliance. This policy provides information on Tufts Health Plan claims adjudication processing guidelines. As every claim is unique, the use of this policy is not a guarantee of payment nor a final prediction of how specific claim(s) will be adjudicated. Claims payment is subject to Member eligibility and benefits on the date of service, coordination of benefits, referral/authorization and utilization management guidelines when applicable, adherence to plan policies and procedures and claims editing logic.

Originated 03/2007, Revised 05/20011

Page 4 of 4 Tufts Medicare Preferred HMO Oncology Payment Policy

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Oncology Payment Policy

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