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.
Why does SUBLOCADE™ (buprenorphine extended-release) injection, for subcutaneous use (CIII) have a miscellaneous J code?
As a newly FDA-approved drug, SUBLOCADE's permanent HCPCS Code, also known as a "J code," will not be issued until 12 to 18 months after approval. Before the J code is assigned, HCPs are able to use the unclassified J code, also known as the "miscellaneous J code", for billing SUBLOCADE. This process is the Centers for Medicare & Medicaid Services' method for managing J codes and payment for new products.
Do insurance providers cover medications with miscellaneous J codes?
Yes, insurance providers have established processes to cover new products that are billed with miscellaneous J codes. To assist in locating coverage details, they may also require the medication brand name and generic name, the National Drug Code (NDC), the strength, the dosage administered, and the route of administration. Some insurance providers may also require additional information to be included on medical claims to support the administration of medications with an unclassified code. The coverage of miscellaneous codes by insurance providers does not necessarily translate into coverage of SUBLOCADE.
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.