Instructions for submitting claims
Step 1: Collect any out-of-pocket costs from the patient
INSUPPORT™ will provide a written Final Benefit Summary to the HCP office and the patient, based on the details communicated by the insurance provider, which will include an estimate of the cost for SUBLOCADE™ (buprenorphine extended-release) injection, for subcutaneous use (CIII) that the patient will be responsible to cover. This portion of the medication cost should be collected from the patient.
Step 3: Reimbursement
If the claim is approved, the patient's insurance provider should provide payment to the HCP office.
Addressing claim denials
A: Identify the reason for the claim denial
If your claim is denied by the patient's insurance provider, you will be notified of the reason why either by INSUPPORT™ or by the insurance provider.
Some of the common reasons for denial include:
- Incomplete or inaccurate information
- Lack of prior authorization
- Diagnosis and procedure coding errors and omissions
- Insufficient medical necessity
B: Request Denied Claim Research from INSUPPORT™
INSUPPORT™ can investigate a denied claim and, if necessary, provide you with the requirements for claim resubmission as communicated by the patient's insurance provider. This service can be requested on page 1 of the INSUPPORT™ Patient Enrollment Form. The patient's denied claim from the insurance provider, the Explanation of Benefits, and a copy of the denial correspondence from the patient's insurance provider are necessary to be submitted to INSUPPORT™, along with the completed Patient Enrollment Form in order for INSUPPORT™ to investigate the denied claim.
Required documents for Denied Claim Research may be submitted via the INSUPPORT™ Provider Portal.
C: Fix any errors and provide additional documentation
Provide any missing information and verify coding information. Submit a Letter of Medical Necessity, if required.
View Sample Letter of Medical Necessity
*The INSUPPORT™ Copay Assistance Program is valid ONLY for patients with private insurance who are prescribed SUBLOCADE for on‑label use. Patients with government insurance are not eligible for the Copay Assistance Program, including, but not limited to, Medicare, Medicaid, Medigap, VA, DoD, TRICARE, CHAMPVA or any other federally or state funded government assisted program. Other restrictions apply.
For more information, please refer to the Terms and Conditions for the INSUPPORT™ Copay Assistance Program for SUBLOCADE.
Receive information from a local Field Reimbursement Specialist (FRS) regarding your access and reimbursement questions.
What is the difference between the J-code and the Q-code?
J and Q‑codes are HCPCS Level II codes that are assigned by CMS to report drugs and biologics. Q‑codes may be assigned and implemented on a quarterly basis while J‑codes are assigned and implemented on an annual basis.
Will new J‑codes be established to replace the Q‑codes?
If CMS establishes new J‑codes for SUBLOCADE, the new codes may be announced in 4th quarter 2018 and may be effective 1st quarter in 2019. If CMS does not establish new J‑codes, offices should continue to use the Q‑codes.
Are insurance payers reimbursing for the Q‑codes?
Yes, in general, all payer types provide reimbursement for correct claims submitted with Q‑codes.
Payers have differing coverage criteria, but in general, provide reimbursement for correct claims submitted with Q‑codes. You should check with individual payers for specific questions.
Do I need to complete the INSUPPORT™ Patient Enrollment Form again to receive Claims Denial Assistance?
If the patient is already enrolled with INSUPPORT™ Hub Services, assistance with researching claim denials is included in this service and another enrollment form is not required. If the patient was not previously enrolled with INSUPPORT™ Hub Services, you and the patient will need to request this service using the Patient Enrollment Form.