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Medical Injectables Program Update: Coding for Inflectra and Renflexis

Based on guidance from the Centers for Medicare & Medicaid Services (CMS), effective April 1, 2018, HCPCS code Q5103 should be used when submitting claims for Inflectra® (infliximab-dyyb) and HCPCS code Q5104 should be used when submitting claims for Reflexis® (infliximab-abda) for services provided on and after April 1, 2018.

When submitting a claim for For date(s) of service Please use HCPCS Code
Inflectra On and after April 1, 2018 Q5103
Inflectra Prior to April 1, 2018 Q5102
Renflexis On and after April 1, 2018 Q5104
Renflexis Prior to April 1, 2018 Q5102

Inflectra and Reflexis are subject to medical necessity and appropriateness review (MNAR) as part of the Horizon Blue Cross Blue Shield of New Jersey Medical Injectables Program (MIP) administered by Magellan Rx Management. Magellan Rx Management conducts medical necessity and appropriateness reviews for additional injectable medications that are administered in a freestanding or hospital-based dialysis center, an outpatient facility, a patient’s home or a physician’s office.¹

A complete list of injectable medications that require MNAR is available online.

Visit our Medical Injectables Program page for more information.

If you have questions, please contact your Network Specialist.

1 Medical necessity and appropriateness review is not required for injectable medications that are administered during an inpatient stay, or in an Emergency Room setting or Observation Room setting.

For medical injectable services rendered in the patient’s home, call 1-855-243-3321 for participating Horizon Care@Home providers to obtain pre-service determination.

Inflectra® is a registered trademark of Pfizer Inc.

Renflexis® is a registered trademark of Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc.

Magellan Rx Management is a service mark of Magellan Health, Inc

Published on: March 2, 2018, 13:54 p.m. ET
Last updated on: March 2, 2018, 14:14 p.m. ET