Wiki Billing J0129 to Medicaid

[Katrinadiperno]

Hi everyone, I work in a Rheumatology office where we perform several injections and infusions weekly. As of recent, Medicaid has denied J0129 Orencia as a non covered charge due to the fact it was recently added to the SAD list. Any advice on how to bill this would be greatly appreciated, as Medicaid does not allow the use of modifiers, otherwise we could append the -JA modifier. Thank you all for any advice given!

 

[Deborah Marsh]

Hi - Have you checked if preauthorization is required? I don't know if this is current or your payer, but it's listed in this doc: https://www.uhcprovider.com/content...P-CC-Prior-Authorization-Effective-5.1.21.pdf

And when I used this tool, it said preauthorization required: https://www.azcompletehealth.com/providers/preauth-check/medicaid-pre-auth.html

 

[marlisemello]

Hello, does anyone know how much medicare would allow for J0129? My provider will pay $4000 to purchase this medication and he wants to know if it is worth it.