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Help with billing Anthem and Tricare S9494

  1. #1
    Colorado Springs, CO
    Question Help with billing Anthem and Tricare S9494
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    I'm hoping someone has an idea what we can do to override a problem we are having between Anthem BCBS and Tricare for Life. We are an infectious disease clinic and many of our patients opt to infuse themselves at home rather than come to the clinic daily. We are not involving a home health agency and provide the patient with all supplies and medications. Anthem requires we bill S9494 with POS 12, however CMS does not allow coverage for this code, therefore Tricare rejects it. Is there any way around this problem, or are we going to have to write off a large sum?

    We have since learned from the patient's account that anytime a federal payer is involved the patient has no choice but to have their infusions in the office due to Anthem's billing requirements. We are just hoping we may get our original patient paid.

    Any help is appreciated, thank you!
    Meg W.
    Billing Specialist
    Infectious Disease Specialists, PC

  2. #2

    Please see this policy from Tricare's Reimbursement Manual:

    S codes [Temporary National Codes (Non-Medicare)] are used by the Blue Cross Blue Shield Association (BCBSA) and the Health Insurance Association of America (HIAA) to report drugs, services
    and supplies for which there are no national codes but which are needed by the private sector to implement policies, programs or claims processing. These codes are not recognized by Medicare and
    are reserved solely for evolving technologies under the TRICARE program until permanent HCPCS/CPT codes can be assigned. As a CSP, home infusion companies are limited to the payment of professional
    services and drugs and supplies provided in the direct treatment of a TRICARE eligible beneficiary. Payment is not allowed for the overall administrative charges/expenses incorporated into the home
    infusion S code per diems.
    Hope this helps.
    Stephan Tong, CPB, CPC, COC
    Medical Billing, Coding, and Credentialing Freelancer | AAPC Certified Biller and Coder | ASC Specialist
    Cell: (323) 360-8270 | Fax: (346) 291-8496 | Website:

  3. Default
    Medical Billing
    Have you tried the Tricare Non Covered Services form? There are a lot of things not covered by Tricare as an exclusion. I've never done it for Tricare 4 Life but regular Tricare allows us to bill patient's directly for those services as long as the beneficiary has been informed before hand and the form correctly filled out.

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