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Chemotherapy Administration

Reimbursement Policy:
Chemotherapy Administration

Effective Date:
August 1, 2007

Last Revised Date:
January 25, 2021

Purpose:
To provide guidelines for the reimbursement of the administration of chemotherapy.

Scope:

All products are included, except products where Horizon BCBSNJ is secondary to Medicare (e.g. Medigap).

All Insured and Administrative Services Only (ASO) accounts are included.

Policy:
Horizon reimburses professionals for both 96413 and 96416 when billed together.

The CPT 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:
Reimbursement will be considered separately for CPT codes 96413 and 96416.

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

  • Group or Individual benefit
  • 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:
7/1/2007: Policy approved
1/25/2021: Added CPT code/nomenclature language to “Policy” section

CPT® is a registered mark of the American Medical Association

Policy 011_v1.0_01252021