ID · Payer & Drug Center
Coverage, Codes and the Files Your Margin Runs On
For a practice that buys its own drugs, these files are the business. This is a curated route to the primary sources — ASP pricing, J-code updates, home infusion policy and coverage — plus the playbooks for working a benefit determination, an authorization and an appeal.
15 verified sources3 operational playbooks
We link, we do not republish. This site prints no reimbursement rates, ASP amounts or fee schedule figures. Payment changes quarterly or annually, varies by locality and contract, and a number copied here would be wrong for someone. Every link below goes to the body that publishes the authoritative version, and every URL was checked before publication.
Coverage, home infusion & policy
The coverage asymmetry between Medicare and commercial insurers is the single structural fact that drives OPAT site of care. Start here rather than with a summary.
- Home Infusion Therapy / Home IVIG ServicesThe Medicare home infusion therapy benefit: eligibility, covered drugs and professional service requirements.cms.gov
- Home infusion billing & ratesCurrent payment rates and billing instructions for the benefit.cms.gov
- Medicare Coverage CenterNational coverage determinations and the coverage database entry point.cms.gov
- Local Coverage DeterminationsWhat your MAC considers reasonable and necessary in your jurisdiction.cms.gov
- Internet-Only ManualsClaims processing and benefit policy manuals when you need the underlying instruction.cms.gov
Drug payment & coding
For a practice that buys its own drugs, these are the files the business runs on. Payment moves quarterly and independently of what you paid for inventory.
- Part B drug ASP pricing filesQuarterly average sales price files — the basis of Medicare payment for separately payable Part B drugs.cms.gov
- HCPCS (including J-codes)Level II code set and quarterly updates. Where a new or changed J-code appears first.cms.gov
- Physician Fee Schedule Look-Up ToolAdministration and professional service payment by code and locality.cms.gov
- NCCI editsProcedure-to-procedure edits behind infusion hierarchy and unbundling denials.cms.gov
- AMA — CPTThe infusion and injection hierarchy and its official guidance.ama-assn.org
Specialty guidance & compliance
Clinical guidance that payer criteria frequently reference, and the compliance frameworks that govern hospital arrangements.
- IDSA practice guidelinesThe guidance payer medical policy most often cites when defining criteria.idsociety.org
- IDSA — antimicrobial stewardshipProgramme structure and evidence, useful when building the institutional case.idsociety.org
- Medicare FFS appealsThe five appeal levels and the deadline at each.cms.gov
- Provider enrolmentEnrolment, revalidation and change reporting.cms.gov
- OIG — physician compliance educationAnti-kickback and self-referral fundamentals before structuring a hospital agreement.oig.hhs.gov
Playbook
Appealing a denied or underpaid drug claim
In drug-heavy practice one claim can outweigh a month of office visits. Rank by dollars and hunt the underpayments.
- 1Rank denials by dollar value, not by count — the ranking inverts completely against a count-based report.
- 2Track hard-denial dollars separately. In buy-and-bill they are realised losses on goods already consumed.
- 3Use root-cause categories specific to this work: authorisation absent or expired, site-of-care mismatch, unit or wastage reporting, medical necessity on the specific agent, administration coding.
- 4Cite the applicable coverage determination or payer criterion you met, rather than appealing on general medical necessity.
- 5Load contracted rates so underpayment is detectable at all, then run a quarterly payment-variance review across your highest-value drug claims.
Playbook
Working a drug authorization
The control standing between inventory and a write-off. The sequence is not negotiable.
- 1Verify coverage, obtain authorisation, acquire drug, administer, bill. Every reordering moves risk onto your balance sheet.
- 2Keep a versioned one-page criteria sheet per drug, per payer: required or not, criteria the documentation must demonstrate, channel, turnaround.
- 3Where clinical urgency requires starting ahead of approval, make it a named exception with a defined approver and a recorded exposure.
- 4Build the authorisation expiry date into the system that schedules the infusions, with an alert far enough ahead to file the extension. This is the most commonly missed step and the most expensive.
- 5Track median time from referral to first dose, and report the ninetieth percentile alongside it — the tail is where the clinical risk sits.
Playbook
Determining the benefit: medical vs pharmacy
Which benefit a drug falls under decides whether your infusion business has drug revenue at all. Establish it at intake, before a therapy plan exists.
- 1Verify coverage and site-of-care eligibility at referral intake, not after the plan is built. This single sequencing change removes most OPAT rework.
- 2Establish whether the payer expects buy-and-bill (medical benefit) or a specialty pharmacy to supply the drug (white-bagging, pharmacy benefit).
- 3Where the drug is supplied to you, confirm delivery timing and storage requirements before scheduling the first dose.
- 4Where you acquire the drug, obtain authorisation before purchase — in buy-and-bill a hard denial is a realised inventory loss, not deferred revenue.
- 5Record the determination on the patient record so downstream staff are not re-litigating it each week.
Commercial payer medical policy portals are not listed here. Each practice’s payer set is different, and a generic list would send you to plans you do not contract with. In production this section becomes a filterable directory scoped to your own contracted payers and state.