Allergy Services

Reimbursement Policy:

Allergy Services

Effective Date:

December 1, 2023

Purpose:

This policy provides guidelines for appropriately billing for allergy immunotherapy.

Scope:

All products are included, except

Products where Horizon is secondary to Medicare (i.e. Medigap)
COB
ITS Home In-Network
FEP
SHBP non MA

All Insured Individual, Commercial medical plans, and Medicare Advantage Plans, are included.

ASO accounts will be included as an Opt-In option for additional claims editing on an account-by-account basis

Definitions:

95165: Professional services for the supervision of preparation and provision of antigens for allergen immunotherapy single or multiple antigens (specify number of doses)

Policy:

Horizon BCBSNJ shall limit the units of 95165 eligible for reimbursement when billed greater than 120 units per year (365 days).

The procedure codes and nomenclature used in this Policy are subject to revision and/or change by the American Medical Association. In the event of such changes, the Policy will continue to be in force, albeit applied to the new or amended coding so issued until such time as the Policy is reviewed and updated to reflect the new or amended coding.

Procedure:

Horizon BCBSNJ shall consider for reimbursement procedure code 95165 in the rolling year (365 days) to one hundred and twenty (120) units.

Horizon BCBSNJ shall deny procedure code 95165 when billed more than 120 units within a rolling year (365 days).

In instances where the provider is participating, based on member benefits, co-payment, coinsurance, and/or deductible shall apply.

In instances where the provider is non-participating, the member's liability shall be up to the provider's charge.

Limitations and Exclusions:

While reimbursement is considered, payment determination is subject to, but not limited to:

The terms and conditions of the applicable health benefit plan
The medical necessity of the services provided
The members' eligibility at the time services are rendered.
The applicable Provider Participation Agreement
Routine claim editing logic, including but not limited to incidental or mutually exclusive logic, and medical necessity
Mandated or legislative required criteria will always supersede.

History:

08/24/2023: Policy approved.

Policy160_v1.0_08242023