PACIFICSOURCE COMMUNICATION UPDATES
CIGNA COMMUNICATION UPDATES
Read Cigna's interim billing guidelines and FAQs here.
Modifier 26 Reimbursement Update
As previously communicated, Cigna planned to implement a change to the administration of reimbursement policy for Current Procedural Terminology (CPT®) codes billed with modifier 26 effective July 10, 2021. After additional review, Cigna decided to delay implementation of Modifier 26 (M26) – Professional Component reimbursement policy update.
The update will no longer be effective July 10, 2021 as originally planned. Cigna will continue to consider the feedback received from providers as the policy update is reevaluated. Cigna will communicate the new implementation date 90 days in advance once a new date has been determined.
Specialty Medical Injectables with Reimbursement Restriction
Effective, July 1, Cigna will expand the Specialty Medical Injectables with Reimbursement Restriction list to include EXONDYS 51 (eteplirsen) and VILTEPSO® (viltolarsen). Guidelines state that certain injectables must be dispensed, and claims submitted, by a Cigna-contracted specialty pharmacy, unless otherwise authorized by Cigna.
The reimbursement restriction list:
- Applies when the specialty medical injectable is administered in an outpatient hospital setting.
- Applies to specialty medical injectables covered under the customer’s medical benefit. Coverage is determined by the customer’s benefit plan.
- Does not apply when the specialty medical injectable is administered in a provider’s office, non-hospital-affiliated ambulatory infusion suite, or home setting.
*Cigna may grant approval for coverage of an initial dose to a facility when medical necessity is met to allow arrangements to obtain the drug from a Cigna-contracted specialty pharmacy.