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Navigating Payer Coverage & Reimbursement | SPRAVATO® (esketamine) HCP

Coding & Reimbursement

SPRAVATO® Coding & Billing

Coding options vary based on acquisition method, health plan requirements, and healthcare services provided

Choose an acquisition method:

HCPCS=Healthcare Common Procedural Coding System; E/M=evaluation and management; REMS=Risk Evaluation and Mitigation Strategy.

*Prolonged codes cannot be used with the SPRAVATO® G codes (G2082 and G2083).

There is currently no unique, designated code to describe the observation and monitoring of SPRAVATO® administration as required by the REMS. Healthcare providers must consult with each patient’s insurance plan since coverage will vary. Please note that healthcare providers are responsible for selecting appropriate codes for any particular claim based on the patient’s condition, the items and services that are furnished, and any specific insurance plan requirements. It is advisable to contact your local insurance plan with regard to local payment policies.

The fact that a drug, device, procedure, or service is assigned an HCPCS code and a payment rate does not imply coverage by the Medicare and/or Medicaid program, but indicates only how the product, procedure, or service may be paid if covered by the program. Fiscal Intermediaries (FIs)/Medicare Administrative Contractors (MACs) and/or State Medicaid program administration determine whether a drug, device, procedure, or other service meets all program requirements for coverage.

This content is presented for informational purposes only and is not intended to provide reimbursement or legal advice, nor does it promise or guarantee coverage, levels of reimbursement, payment, or charge. Similarly, all CPT® and HCPCS codes are supplied for informational purposes only and represent no statement, promise, or guarantee by Janssen Pharmaceuticals, Inc., that these codes will be appropriate or that reimbursement will be made. It is not intended to increase or maximize reimbursement by any payer. Laws, regulations, and policies concerning reimbursement are complex and are updated frequently. While we have made an effort to be current as of the issue date of this document, the information may not be as current or comprehensive when you view it. We strongly recommend you consult the payer organization for its reimbursement policies.

CPT®=Current Procedural Terminology. CPT® is a registered trademark of the American Medical Association. All rights reserved.

 

HCPCS=Healthcare Common Procedural Coding System; E/M=evaluation and management; REMS=Risk Evaluation and Mitigation Strategy.

*Prolonged codes cannot be used with the SPRAVATO® G codes (G2082 and G2083).

There is currently no unique, designated code to describe the observation and monitoring of SPRAVATO® administration as required by the REMS. Healthcare providers must consult with each patient’s insurance plan since coverage will vary. Please note that healthcare providers are responsible for selecting appropriate codes for any particular claim based on the patient’s condition, the items and services that are furnished, and any specific insurance plan requirements. It is advisable to contact your local insurance plan with regard to local payment policies.

The fact that a drug, device, procedure, or service is assigned an HCPCS code and a payment rate does not imply coverage by the Medicare and/or Medicaid program, but indicates only how the product, procedure, or service may be paid if covered by the program. Fiscal Intermediaries (FIs)/Medicare Administrative Contractors (MACs) and/or State Medicaid program administration determine whether a drug, device, procedure, or other service meets all program requirements for coverage.

This content is presented for informational purposes only and is not intended to provide reimbursement or legal advice, nor does it promise or guarantee coverage, levels of reimbursement, payment, or charge. Similarly, all CPT® and HCPCS codes are supplied for informational purposes only and represent no statement, promise, or guarantee by Janssen Pharmaceuticals, Inc., that these codes will be appropriate or that reimbursement will be made. It is not intended to increase or maximize reimbursement by any payer. Laws, regulations, and policies concerning reimbursement are complex and are updated frequently. While we have made an effort to be current as of the issue date of this document, the information may not be as current or comprehensive when you view it. We strongly recommend you consult the payer organization for its reimbursement policies.

CPT®=Current Procedural Terminology. CPT® is a registered trademark of the American Medical Association. All rights reserved.

 

Have Questions About Billing and Reimbursement? We Can Help Get Answers

At Janssen, we get that there's a lot that goes into managing billing and reimbursement, so we've put together information you may need for SPRAVATO®.

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Please see the SPRAVATO® Access & Reimbursement Guide for more information on coding and billing.

Considerations for Payer Discussions

Discussing terms with payers may help minimize claim denials for SPRAVATO® and facilitate timely and accurate reimbursement

Consider the following checklist when reviewing potential terms with your top 5 to 10 payers:

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    Historical and current reimbursement rates

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    Number of days that each payer is required to provide reimbursement

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    Number of days that your treatment center must submit claims for SPRAVATO® and associated healthcare services

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    List of healthcare services covered by each payer

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    Appropriate CPT® codes

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    Appeals process if a claim is denied for clinical reasons

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    Expiration/termination timelines

CPT®=Current Procedural Terminology. CPT® is a registered trademark of the American Medical Association. All rights reserved.

This content is presented for informational purposes only and is not intended to provide reimbursement or legal advice, nor does it promise or guarantee coverage, levels of reimbursement, payment, or charge. Similarly, all CPT® and HCPCS codes are supplied for informational purposes only and represent no statement, promise, or guarantee by Janssen Pharmaceuticals, Inc., that these codes will be appropriate or that reimbursement will be made. It is not intended to increase or maximize reimbursement by any payer. Laws, regulations, and policies concerning reimbursement are complex and are updated frequently. While we have made an effort to be current as of the issue date of this document, the information may not be as current or comprehensive when you view it. We strongly recommend you consult the payer organization for its reimbursement policies.

Payer Coverage Policies

Coverage for SPRAVATO® is dependent on many factors, including:

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    The patient’s insurance type (eg, commercial, Medicare, Medicaid)

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    Whether SPRAVATO® is covered under the medical or pharmacy benefit

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    Specific payer requirements

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    The site of care in which SPRAVATO® is administered

Consider the 3 components of access when documenting payer and employer requirements:

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Drug Coverage
  • Have both the medical benefit and pharmacy benefit been checked for coverage?
  • Does the payer/employer require a letter of medical necessity for coverage?
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Drug Procurement
  • Is it confirmed the chosen pharmacy can process Assignment of Benefits (AOB) for the payer/employer?
  • Is it confirmed the chosen pharmacy is in-network for the payer/employer?
  • What pharmacy forms are needed in order to process prescriptions?
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Service Coding
  • Are observation and monitoring services covered directly by the payer/employer, or are they managed by a behavioral health organization?
  • Is there a contract in place with the entity that is covering the services and the appropriate codes in those contracts?
  • When utilizing the buy-and-bill process, does the payer/employer prefer use of a bundled G code or S code?
  • Do the billable and reimbursed amounts match?

Exceptions & Appeals

If the benefits investigation determines that SPRAVATO® is subject to restrictions or not covered, consider submitting a medical exception request to the patient’s health plan

Letter of Exception

  • An exception request is a specific type of coverage determination that asks a payer to reconsider an adverse tiering or formulary decision. Access a sample Letter of Exception template to create your own letter to request an exception for SPRAVATO®.

If a PA or medical exception request is denied for clinical reasons, consider submitting an appeal request to the patient’s health plan

Letter of Medical Necessity

  • Access a sample Letter of Medical Necessity template to create your letter documenting the medical necessity of treatment with SPRAVATO® for your patient. You may submit the letter to the payer either with the initial claim or when requesting reconsideration of a denied claim.