296 Form

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Pharmacy Medical Policy Home Total Parenteral Nutrition (TPN) Table of Contents
• Policy: Commercial • Information Pertaining to All Policies • Endnotes
• Coding Information • References • Forms • Policy History

Policy Number: 296 BCBSA Reference Number: None Policy Commercial Members: Managed Care (HMO and POS), PPO, and Indemnity

Note: All requests for indications listed and not listed on the medical policy guidelines may be submitted to BCBSMA Pharmacy Operations by completing the Prior Authorization Form on the last page of this document.

This medication is not covered by the pharmacy benefit. It is covered by the Medical Benefit or as a Home Infusion Therapy. Prior Authorization Information ☒ Prior Authorization ☐ Step Therapy ☐ Quality Care Dosing

Pharmacy Operations: Tel: 1-800-366-7778 Fax: 1-800-583-6289 Policy last updated 7/1/2023 Pharmacy (Rx) or Medical (MED) benefit coverage ☐ Rx ☒ MED To request for coverage: Physicians may call, fax, or mail the attached form (Formulary Exception/Prior Authorization form) to the address below.
Blue Cross Blue Shield of Massachusetts Pharmacy Operations Department 25 Technology Place Hingham, MA 02043

Individual Consideration: Policy for requests that do not meet clinical criteria of this policy, see section labeled Individual Consideration
Policy applies to Commercial Members:
• Managed Care (HMO and POS),
• PPO and Indemnity • MEDEX with Rx plan • Managed Major Medical with Custom BCBSMA Formulary • Comprehensive Managed Major Medical with Custom BCBSMA Formulary • Managed Blue for Seniors with Custom BCBSMA Formulary

2 We may cover medically necessary total parenteral nutrition (TPN) in the home3 for conditions resulting in impaired intestinal absorption and/or resulting in abnormal food intake, including, but not limited to, any of the following:1,9 • Crohn’s disease • CNS disorder resulting in swallowing difficulties and high risk of aspiration • Hyperemesis gravidarum.6 • Intestinal pseudo-obstruction • Massive small bowel resection with inadequate remaining resorptive capacity (short gut syndrome) • Single6,7,8 or multiple fistulae (enterocolic, enterovesical, or enterocutaneous) • Newborn anomalies of the gastrointestinal tract which prevent or contraindicate oral feeding such as tracheo-esophageal fistula, gastroschisis, omphalocele, or massive intestinal atresia • Infants and young children who fail to thrive due to cardiac or respiratory disease, short bowel syndrome, malabsorption, or chronic idiopathic diarrhea • Prolonged paralytic ileus after major surgery or multiple injuries • Malabsorption due to Whipple’s disease • Malabsorption due to chronic infectious enteritis • Severe forms of Protein-Energy Undernutrition (PEU) [i.e. ALB ≤ 2.4] • Radiation enteritis • Chronic pancreatitis4 • Severe acute pancreatitis6,7,8 • Pancreatic pseudocysts4 • Obstructing stricture8 or cancer of the mouth, esophagus, stomach1 or intestine6 • Post stem cell transplant patients and specifically those with graft vs. host disease6

Eligible patients must meet the following: In some circumstances such as anticipation of prolonged course of illness, all of these criteria need not be applied: • Weight is significantly less than normal for age and height compared to pre-illness weight • BUN less than 10 (not an accurate marker in renal failure patients) • Patients are unable to receive more than 30% of caloric requirements enterally. NOTE: There are no kilocalories minimums in pediatric patients.

We may cover medically necessary intradialytic parenteral nutrition (IDPN) as an alternative to a regularly scheduled regimen of total parenteral nutrition (TPN) only in those patients who would be considered candidates for TPN (see TPN coverage above.)10

We do not cover TPN in the home:9 • To increase protein or caloric intake in addition to the patient’s daily diet9 • In patients with a stable nutritional status, in whom only short-term parenteral nutrition might be required for less than 2 weeks9 • For routine pre and/or postoperative care.9

We do not cover intradialytic parenteral nutrition (IDPN) in those patients who would be considered a candidate for TPN but for whom the intradialytic parenteral nutrition is not offered as an alternative to TPN, but in addition to regularly scheduled infusions to TPN.

We do not cover intradialytic parenteral nutrition in patients who would not otherwise be considered candidates for TPN.

Other Information Home total parenteral nutrition (TPN) is payable to contracted home infusion therapy providers only.

We do not separately reimburse the following: B4220 (parenteral nutrition supply kit; pre mix, per day), B4222 (parenteral nutrition supply kit; home mix, per day), B4224 (parenteral nutrition administration kit, per day), B9004-B9006 (parenteral nutrition infusion pump), syringes, discard boxes, thermometers,

3 specimen cups, scissors, or hyperalimentation storage units. The listed supplies are included in the per diem rate and will reject leaving no patient balance.

TPN is considered primary therapy when multiple therapies are administered on the same date of service. The services would be paid as Y9598 (multiple therapies). CPT Codes / HCPCS Codes / ICD Codes The following codes are included below for informational purposes. Inclusion or exclusion of a code does not constitute or imply member coverage or provider reimbursement. Please refer to the member’s contract benefits in effect at the time of service to determine coverage or non-coverage as it applies to an individual member. A draft of future ICD-10 Coding related to this document, as it might look today, is included below for your reference.

Providers should report all services using the most up-to-date industry-standard procedure, revenue, and diagnosis codes, including modifiers where applicable. CPT Codes There is no specific CPT code for this service.

HCPCS Codes HCPCS codes: Code Description B4164 Parenteral nutrition solution: carbohydrates (dextrose), 50% or less (500 ml = 1 unit), home mix B4168 Parenteral nutrition solution; amino acid, 3.5%, (500 ml = 1 unit) - home mix B4172 Parenteral nutrition solution; amino acid, 5.5% through 7%, (500 ml = 1 unit) - home mix B4176 Parenteral nutrition solution; amino acid, 7% through 8.5%, (500 ml = 1 unit) - home mix B4178 Parenteral nutrition solution: amino acid, greater than 8.5% (500 ml = 1 unit), home mix B4180 Parenteral nutrition solution: carbohydrates (dextrose), greater than 50% (500 ml = 1 unit), home mix B4185 Parenteral nutrition solution, per 10 grams lipids B4189 Parenteral nutrition solution: compounded amino acid and carbohydrates with electrolytes, trace elements, and vitamins, including preparation, any strength, 10 to 51 g of protein, premix B4193 Parenteral nutrition solution: compounded amino acid and carbohydrates with electrolytes, trace elements, and vitamins, including preparation, any strength, 52 to 73 g of protein, premix B4197 Parenteral nutrition solution; compounded amino acid and carbohydrates with electrolytes, trace elements and vitamins, including preparation, any strength, 74 to 100 grams of protein - premix B4199 Parenteral nutrition solution; compounded amino acid and carbohydrates with electrolytes, trace elements and vitamins, including preparation, any strength, over 100 grams of protein - premix B4216 Parenteral nutrition; additives (vitamins, trace elements, Heparin, electrolytes), home mix, per day B4220 Parenteral nutrition supply kit; premix, per day B4222 Parenteral nutrition supply kit; home mix, per day B4224 Parenteral nutrition administration kit, per day B5000 Parenteral nutrition solution: compounded amino acid and carbohydrates with electrolytes, trace elements, and vitamins, including preparation, any strength, renal - Amirosyn RF, NephrAmine, RenAmine - premix

4 B5100 Parenteral nutrition solution: compounded amino acid and carbohydrates with electrolytes, trace elements, and vitamins, including preparation, any strength, hepatic - FreAmine HBC, HepatAmine - premix B5200 Parenteral nutrition solution: compounded amino acid and carbohydrates with electrolytes, trace elements, and vitamins, including preparation, any strength, stress

• branch chain amino acids - premix B9004 Parenteral nutrition infusion pump, portable B9006 Parenteral nutrition infusion pump, stationary S9364 Home infusion therapy, total parenteral nutrition (TPN); administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment including standard TPN formula (lipids, specialty amino acid formulas, drugs other than in standard formula and nursing visits coded separately), per diem (do not use with home infusion codes S9365-S9368 using daily volume scales) S9365 Home infusion therapy, total parenteral nutrition (TPN); 1 liter per day, administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment including standard TPN formula (lipids, specialty amino acid formulas, drugs other than in standard formula and nursing visits coded separately), per diem S9366 Home infusion therapy, total parenteral nutrition (TPN); more than 1 liter but no more than 2 liters per day, administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment including standard TPN formula (lipids, specialty amino acid formulas, drugs other than in standard formula and nursing visits coded separately), per diem S9367 Home infusion therapy, total parenteral nutrition (TPN); more than 2 liters but no more than 3 liters per day, administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment including standard TPN formula (lipids, specialty amino acid formulas, drugs other than in standard formula and nursing visits coded separately), per diem S9368 Home infusion therapy, total parenteral nutrition (TPN); more than 3 liters per day, administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment including standard TPN formula (lipids, specialty amino acid formulas, drugs other than in standard formula and nursing visits coded separately), per diem ICD-10 Diagnosis Codes ICD-10-CM Diagnosis codes: Code Description A09 Infectious gastroenteritis and colitis, unspecified B25.2 Cytomegaloviral pancreatitis C04.0 Malignant neoplasm of anterior floor of mouth C04.1 Malignant neoplasm of lateral floor of mouth C04.8 Malignant neoplasm of overlapping sites of floor of mouth C04.9 Malignant neoplasm of floor of mouth, unspecified C05.0 Malignant neoplasm of hard palate C05.1 Malignant neoplasm of soft palate C05.2 Malignant neoplasm of uvula C05.8 Malignant neoplasm of overlapping sites of palate C05.9 Malignant neoplasm of palate, unspecified C06.0 Malignant neoplasm of cheek mucosa C06.1 Malignant neoplasm of vestibule of mouth C06.2 Malignant neoplasm of retromolar area C06.80 Malignant neoplasm of overlapping sites of unspecified parts of mouth

5 C06.89 Malignant neoplasm of overlapping sites of other parts of mouth C06.9 Malignant neoplasm of mouth, unspecified C15.3 Malignant neoplasm of upper third of esophagus C15.4 Malignant neoplasm of middle third of esophagus C15.5 Malignant neoplasm of lower third of esophagus C15.8 Malignant neoplasm of overlapping sites of esophagus C15.9 Malignant neoplasm of esophagus, unspecified C16.0 Malignant neoplasm of cardia C16.1 Malignant neoplasm of fundus of stomach C16.2 Malignant neoplasm of body of stomach C16.3 Malignant neoplasm of pyloric antrum C16.4 Malignant neoplasm of pylorus C16.5 Malignant neoplasm of lesser curvature of stomach, unspecified C16.6 Malignant neoplasm of greater curvature of stomach, unspecified C16.8 Malignant neoplasm of overlapping sites of stomach C16.9 Malignant neoplasm of stomach, unspecified C17.0 Malignant neoplasm of duodenum C17.1 Malignant neoplasm of jejunum C17.2 Malignant neoplasm of ileum C17.3 Meckel's diverticulum, malignant C17.8 Malignant neoplasm of overlapping sites of small intestine C17.9 Malignant neoplasm of small intestine, unspecified C18.0 Malignant neoplasm of cecum C18.1 Malignant neoplasm of appendix C18.2 Malignant neoplasm of ascending colon C18.3 Malignant neoplasm of hepatic flexure C18.4 Malignant neoplasm of transverse colon C18.5 Malignant neoplasm of splenic flexure C18.6 Malignant neoplasm of descending colon C18.7 Malignant neoplasm of sigmoid colon C18.8 Malignant neoplasm of overlapping sites of colon C18.9 Malignant neoplasm of colon, unspecified C26.0 Malignant neoplasm of intestinal tract, part unspecified D00.00 Carcinoma in situ of oral cavity, unspecified site D00.01 Carcinoma in situ of labial mucosa and vermilion border D00.02 Carcinoma in situ of buccal mucosa D00.03 Carcinoma in situ of gingiva and edentulous alveolar ridge D00.04 Carcinoma in situ of soft palate D00.05 Carcinoma in situ of hard palate D00.06 Carcinoma in situ of floor of mouth D00.07 Carcinoma in situ of tongue D00.08 Carcinoma in situ of pharynx D00.1 Carcinoma in situ of esophagus D00.2 Carcinoma in situ of stomach D01.0 Carcinoma in situ of colon D01.40 Carcinoma in situ of unspecified part of intestine D01.49 Carcinoma in situ of other parts of intestine D89.813 Graft-versus-host disease, unspecified J86.0 Pyothorax with fistula K22.2 Esophageal obstruction K31.89 Other diseases of stomach and duodenum

6 K31.9 Disease of stomach and duodenum, unspecified K50.00 Crohn's disease of small intestine without complications K50.011 Crohn's disease of small intestine with rectal bleeding K50.012 Crohn's disease of small intestine with intestinal obstruction K50.013 Crohn's disease of small intestine with fistula K50.014 Crohn's disease of small intestine with abscess K50.018 Crohn's disease of small intestine with other complication K50.019 Crohn's disease of small intestine with unspecified complications K50.10 Crohn's disease of large intestine without complications K50.111 Crohn's disease of large intestine with rectal bleeding K50.112 Crohn's disease of large intestine with intestinal obstruction K50.113 Crohn's disease of large intestine with fistula K50.114 Crohn's disease of large intestine with abscess K50.118 Crohn's disease of large intestine with other complication K50.119 Crohn's disease of large intestine with unspecified complications K50.80 Crohn's disease of both small and large intestine without complications K50.811 Crohn's disease of both small and large intestine with rectal bleeding K50.812 Crohn's disease of both small and large intestine with intestinal obstruction K50.813 Crohn's disease of both small and large intestine with fistula K50.814 Crohn's disease of both small and large intestine with abscess K50.818 Crohn's disease of both small and large intestine with other complication K50.819 Crohn's disease of both small and large intestine with unspecified complications K50.90 Crohn's disease, unspecified, without complications K50.911 Crohn's disease, unspecified, with rectal bleeding K50.912 Crohn's disease, unspecified, with intestinal obstruction K50.913 Crohn's disease, unspecified, with fistula K50.914 Crohn's disease, unspecified, with abscess K50.918 Crohn's disease, unspecified, with other complication K50.919 Crohn's disease, unspecified, with unspecified complications K51.012 Ulcerative (chronic) pancolitis with intestinal obstruction K51.013 Ulcerative (chronic) pancolitis with fistula K51.212 Ulcerative (chronic) proctitis with intestinal obstruction K51.213 Ulcerative (chronic) proctitis with fistula K51.312 Ulcerative (chronic) rectosigmoiditis with intestinal obstruction K51.313 Ulcerative (chronic) rectosigmoiditis with fistula K51.412 Inflammatory polyps of colon with intestinal obstruction K51.413 Inflammatory polyps of colon with fistula K51.512 Left sided colitis with intestinal obstruction K51.513 Left sided colitis with fistula K51.812 Other ulcerative colitis with intestinal obstruction K51.813 Other ulcerative colitis with fistula K51.912 Ulcerative colitis, unspecified with intestinal obstruction K51.913 Ulcerative colitis, unspecified with fistula K52.0 Gastroenteritis and colitis due to radiation K52.89 Other specified noninfective gastroenteritis and colitis K56.0 Paralytic ileus K56.60 Unspecified intestinal obstruction K56.69 Other intestinal obstruction K56.7 Ileus, unspecified K59.8 Other specified functional intestinal disorders K59.9 Functional intestinal disorder, unspecified

7 K63.2 Fistula of intestine K86.0 Alcohol-induced chronic pancreatitis K86.1 Other chronic pancreatitis K86.2 Cyst of pancreas K86.3 Pseudocyst of pancreas K90.81 Whipple's disease K90.89 Other intestinal malabsorption K90.9 Intestinal malabsorption, unspecified K91.2 Postsurgical malabsorption, not elsewhere classified N32.1 Vesicointestinal fistula O21.1 Hyperemesis gravidarum with metabolic disturbance O21.2 Late vomiting of pregnancy O21.8 Other vomiting complicating pregnancy O21.9 Vomiting of pregnancy, unspecified Q41.0 Congenital absence, atresia and stenosis of duodenum Q41.1 Congenital absence, atresia and stenosis of jejunum Q41.2 Congenital absence, atresia and stenosis of ileum Q41.8 Congenital absence, atresia and stenosis of other specified parts of small intestine Q41.9 Congenital absence, atresia and stenosis of small intestine, part unspecified Q42.0 Congenital absence, atresia and stenosis of rectum with fistula Q42.1 Congenital absence, atresia and stenosis of rectum without fistula Q42.2 Congenital absence, atresia and stenosis of anus with fistula Q42.3 Congenital absence, atresia and stenosis of anus without fistula Q42.8 Congenital absence, atresia and stenosis of other parts of large intestine Q42.9 Congenital absence, atresia and stenosis of large intestine, part unspecified Q79.2 Exomphalos Q79.3 Gastroschisis R19.7 Diarrhea, unspecified R62.51 Failure to thrive (child) Z94.84 Stem cells transplant status ICD-10 Procedure Codes ICD-10-PCS procedure codes: Code Description 3E0336Z Introduction of Nutritional Substance into Peripheral Vein, Percutaneous Approach 3E0436Z Introduction of Nutritional Substance into Central Vein, Percutaneous Approach Individual Consideration All our medical policies are written for the majority of people with a given condition. Each policy is based on medical science. For many of our medical policies, each individual’s unique clinical circumstances may be considered in light of current scientific literature. Physicians may send relevant clinical information for individual patients for consideration to:

Blue Cross Blue Shield of Massachusetts Pharmacy Operations Department 25 Technology Place Hingham, MA 02043
Tel: 1-800-366-7778 Fax: 1-800-583-6289

8 Policy History Date Action 72023/ Reformatted Policy. 1/2018 Updated to include severe PEU as part of the criteria. 6/2017 Updated address for Pharmacy Operations. 10/2016 Clarified coding information.
7/2014 Updated Coding section with ICD10 procedure and diagnosis codes, effective 10/2015. 1/2014 Updated ExpressPAth Language and removed Blue Value. 11/2011-4/2012 Medical policy ICD 10 remediation: Formatting, editing and coding updates.
No changes to policy statements.
2/2012 Updated to correct employee fax number on Home Infusion Therapy Authorization Form. 2/2012 BCBSA National medical policy review. No changes to policy statements. 2/2012 BCBSA National medical policy review. No changes to policy statements. 10/2011 Reviewed - Medical Policy Group - Gastroenterology, Nutrition and Organ Transplantation. No changes to policy statements. 11/2010 Reviewed - Medical Policy Group - Gastroenterology, Nutrition and Organ Transplantation. No changes to policy statements. 1/2010 BCBSA National medical policy review. Changes to policy statements. 11/2009 Reviewed - Medical Policy Group - Gastroenterology, Nutrition and Organ Transplantation. No changes to policy statements. 7/2009 Updated format, definitions removed.
11/2008 Reviewed - Medical Policy Group - Gastroenterology, Nutrition and Organ Transplantation. No changes to policy statements. 9/2008 BCBSA National medical policy review. No changes to policy statements. 11/2007 Reviewed - Medical Policy Group - Gastroenterology, Nutrition and Organ Transplantation. No changes to policy statements. 8/2007 BCBSA National medical policy review. No changes to policy statements. References

1. Office of Health Technology Assessment (OHTA). Intradialytic parenteral nutrition for hemodialysis patients. Health Technology Review, No. 6, August, 1993. (AHCPR Pub. No. 93-0068 accessible at http://hstat.nlm.nih.gov/hq/Hquest/screen/directaccess/db/147)
2. Foulks CJ. An evidence-based evaluation of intradialytic parenteral nutrition. Am J Kidney Dis 1999; 33(1):186-92.
3. Chertow GM, Ling J, Lew NL et al. The association of intradialytic parenteral nutrition administration with survival in hemodialysis patients. Am J Kidney Dis 1994; 24(6):912-20.
4. Foulks CJ. The effect of intradialytic parenteral nutrition on hospitalization rate and mortality in malnourished hemodialysis patients. J Ren Nutr 1994; 4(1):5-10.
5. Capelli JP, Kushner H, Camiscioli TC et al. Effect of intradialytic parenteral nutrition on mortality rates in end stage renal disease care. Am J Kidney Dis 1994; 23(6):808-16.
6. Pupim LB, Flakoll PJ, Brouillette JR et al. Intradialytic parenteral nutrition improves protein and energy homeostasis in chronic hemodialysis patients. J Clin Invest 2002; 110(4):483-92.

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7. Mitch WE. Malnutrition: a frequent misdiagnosis for hemodialysis patients. J Clin Invest 2002;
8. Kopple JD. The National Kidney Foundation K/DOQI clinical practice guidelines for dietary protein intake for chronic dialysis patients. Am J Kidney Dis 2001; 38(4 suppl 1):S68-73.
9. Pupim LB, Majchrzak KM, Flakoll PJ et al. Intradialytic oral nutrition improves protein homeostasis in chronic hemodialysis patients with deranged nutritional status. J Am Soc Nephrol 2006; 17(11):3149-
11. Korzets A, Azoulay O, Ori Y et al. The use of intradialytic parenteral nutrition in acutely ill haemodialysed patients. J Ren Care 2008; 34(1):14-8.
12. Cano NJ, Fouque D, Roth H et al. Intradialytic parenteral nutrition does not improve survival in malnourished hemodialysis patients: a 2-year multicenter, prospective, randomized study. J Am Soc Nephrol 2007; 18(9):2583-91.
13. Ikizler TA. Parenteral nutrition offers no benefit over oral supplementation in malnourished hemodialysis patients. Nat Clin Pract Nephrol 2008; 4(2):76-7.
14. Dezfuli A, Scholl D, Lindenfeld SM et al. Severity of hypoalbuminemia predicts response to intradialytic parenteral nutrition in hemodialysis patients. J Ren Nutr 2009; 19(4):291-7.
15. Dukkipati R, Kalantar-Zadeh K, Kopple JD. Is there a role for intradialytic parenteral nutrition? A review of the evidence. Am J Kidney Dis 2010; 55(2):352-64.
16. KDOQI Work Group. KDOQI Clinical Practice Guideline for Nutrition in Children with CKD: 2008. Am J Kidney Dis 2009; 53(3 suppl 2):S11-104.
17. Druml W, Kierdorf HP; Working group for developing the guidelines for parenteral nutrition of The German Association for Nutritional Medicine. Parenteral nutrition in patients with renal failure - Guidelines on Parenteral Nutrition, Chapter 17. Ger Med Sci 2009; 7:Doc11.
18. Kopple JD, Foulks CJ, Piraino B et al. Proposed Health Care Financing Administration guidelines for the reimbursement of enteral and parenteral nutrition. Am J Kidney Dis 1995; 26(6):995-7.
19. HCFA Rulings. Available online at; https://www.cms.gov/Rulings/downloads/hcfar963.pdf. Last accessed June 2011.
    Endnotes
20. Based upon the 7/1996 National Blue Cross Blue Shield Association policy guideline on TPN and Enteral Nutrition in the Home, based upon a literature search from 1/1992 through 4/1995.
21. Based upon a 10/1996 national Blue Cross Blue Shield Association policy.
22. Based upon a 7/1995 AMA DATTA (Diagnostic and Therapeutic Technology Assessment) entitled Peripheral Parenteral Nutrition, Glade MJ. .
23. Recommendations from Medical Policy Group Meeting, May 2000
24. Recommendations from the 5/2001 GI Medical Policy Group meeting. For additional information see also Medicare’s website at: http://www.umd.nycpic.com/ch18_parenteral.html.
25. Recommendations from Bruce Bistrian, MD, Chief of Clinical Nutrition from Beth Israel Hospital; June 2003
26. Recommendations from Douglas Wilmore, MD, Metabolic Support, Brigham and Women’s Hospital; June 2003.
27. Recommendations from David Burns, MD, Nutrition Support, Lahey Clinic Medical Center; June 2003
28. Based upon the 2003 National Policy Based Blue Cross Blue Shield Association national policy 1.02.01, Total Parenteral Nutrition and enteral Nutrition in the Home.

29. Based upon BCBSA National Policy 8.01.44 Intradialytic Parenteral Nutrition (IDPN). Reviewed 6/2011.

    To request prior authorization using the Massachusetts Standard Form for Medication Prior Authorization Requests (eForm), click the link below: http://www.bluecrossma.org/medical-policies/sites/g/files/csphws2091/files/acquiadam- assets/023%20E%20Form%20medication%20prior%20auth%20instruction%20prn.pdf

10 Home Infusion Therapy - Total Parenteral Nutrition (TPN) Prior Authorization Form

Please complete and fax with the physician's prescription to: (888) 641-5355. If the patient is a BCBSMA employee, please fax the form to: (617)246-4013. Company name:

Contact Name:

Phone #:

Provider #:

Fax#

Address:

Patient name:

Address:

Patient ID#:

DOB://____ Diagnosis:

Prescribing Physician/addr:
____ Telephone:

PCP name/address: ____ Telephone:

Is this fax number ‘secure’ for PHI receipt/transmission per HIPAA requirements? (circle one) Yes No Type of Therapy



TPN: Grams Amino Acids/Day Days/Weeks Grams Lipids/Day Days/Week Primary Therapy Primary drug name:

Approximate duration: // to // Dose:

Frequency:

Route of administration:

Other Therapy Other drug name:

Approximate duration: // to // Dose:

Frequency

Route of administration:  Initial Certification  Recertification  If this is a “drug only” authorization request, indicate other services the nursing agency is providing: __ Nursing provided by: __
Contact: ____ Phone: _Fax:__

Request for 7 Day Coverage: Date of occurrence:___ Request dates:____
Occurrence type:  Hospitalization  Death  Change of Therapy

Physician signature:
Date:____ OR

 

Copy of physician signed prescription is REQUIRED with this request