ForwardHealth enddated NDCs for Synagis® in ForwardHealth interChange effective for DOS on and after October 15, 2009. Therefore, pharmacy providers can no longer submit claims for Synagis® (palivizumab) using the real-time POS system, NCPDP version 5.1, or the Noncompound Drug Claim form.
Providers who submit claims for Synagis® for DOS before October 15, 2009, on the NCPDP 5.1 Telecommunication Standard Format for Retail Pharmacy Claims are required to indicate the NDC on the drug being dispensed. Currently, the NDCs for Synagis® are 60574-4112-01 (Synagis® 50mg vials) and 60574-4111-01 (Synagis® 100mg vials). These NDCs are subject to change. Refer to the product being dispensed for the correct NDC.
Providers who submit claims on the 837P or the paper 1500 Health Insurance Claim Form are required to indicate CPT code 90378 (Respiratory syncytial virus immune globulin [RSV-IgIM], for intramuscular use, 50 mg, each) with the appropriate unit that indicates administered dosage (e.g., 1 unit equals 50 mg) on each claim submission.
Children must be under 24 months of age to begin receiving treatment with the drug. If the child turns two during the treatment season, the treatment may continue if the provider submits a completed Pharmacy Special Handling Request form and a Noncompound Drug Claim form to ForwardHealth. Providers should check the pharmacy consultant review box on the Pharmacy Special Handling Request form and indicate an age-restriction override. Providers should mail completed Pharmacy Special Handling Requests and Noncompound Drug Claim forms to the address indicated on the Pharmacy Special Handling Request.
Providers of physician services may submit a completed 1500 Health Insurance Claim Form, a request for an age restriction override, and a request for medical consultant review to the following address:
ForwardHealth
Written Correspondence
6406 Bridge Rd
Madison WI 53784-0005
For DOS before October 15, 2009, pharmacy providers may submit claims for partial quantities of Synagis® through the real-time pharmacy POS system or on the Noncompound Drug Claim form. For example, when 120 milligrams of Synagis® are dispensed, providers are required to indicate "1.2" in Element 15 of the Noncompound Drug Claim form. For providers who submit claims on the 837P or 1500 Health Insurance Claim Form, if a partial amount is administered, providers are required to indicate the partial amount instead of the whole amount.