• Coding
• Claims Filing
• Sample CMS-1500 Claim Form

Coding

Using the most accurate and specific codes is an essential step to ensure proper claims processing and adequate reimbursement. Claims submission requirements may vary by payor and depend on whether you are billing for the teaching dose of Kineret^® or for ongoing therapy with Kineret^®.

Kineret^®: Physician Office-Administered Teaching Dose
Coding for the teaching dose of Kineret^® will require the use of multiple coding systems to adequately reflect the time and resources expended during the visit. An overview of each coding system and the recommended codes are shown below.

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Current Procedural Terminology (CPT^®1-4)
CPT-4 codes list services and procedures performed by healthcare providers. Physicians are not reimbursed separately for educating the patient regarding administering Kineret^®; instead, this reimbursement is included in the payment received for other services billed, such as the physician office visit or the injection itself. In addition, physicians cannot typically bill for both an office visit and an injection. Therefore, if the physician opts to bill for the injection, the most appropriate code will likely be 90782, Therapeutic or diagnostic injection; subcutaneous or intramuscular. Additionally, drugs administered during this teaching dose session are usually also billed.

National Drug Code (NDC)
NDCs are numbers assigned by the Food and Drug Administration (FDA). These numbers are typically used to bill payors for the drugs received. To advise payors of the specific drug provided, most claims submitted for Kineret^® should include the NDC number for:

• All claims submitted electronically by pharmacies
• All claims submitted by physician offices for the teaching dose of Kineret^®
• Most claims submitted manually by patients

The NDC number for Kineret^® is 55513-177-28.

Kineret^®: Ongoing Therapy
Coding for ongoing therapy with Kineret^® will vary depending upon the individual billing (pharmacy or patient) and the individual payor. At a minimum, most payors will require use of the NDC number for Kineret^® on the claim form.

If you have any questions regarding the most appropriate codes to use when billing for Kineret^®, please call the Kineret^® Customer Call Center at
1-866-KINERET (1-866-546-3738).

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Claims Filing

Verification of coverage is key to determining how to submit claims for Kineret^®. Plans may cover Kineret^® through a prescription drug benefit, a medical benefit, or an injectable rider. Depending upon the payor type or specific plan, each benefit structure may have different claim submission requirements. A general overview of claim submission considerations follows. To understand the requirements for a patient-specific claim submission, it will be important to verify this information directly with the payor.

Kineret^®: Physician Office-Administered Teaching Dose
Services performed in the physician office setting are typically billed using the CMS-1500 claim form. The accuracy and completeness of the claim is key to timely and appropriate reimbursement. We have provided a sample CMS-1500 claim form for you to use as a resource.

Sometimes it is helpful to also include the following:

• Kineret^® Patient Product Information
• Copies of journal articles regarding the efficacy and safety of Kineret^®
• Although most patients will bring Kineret^® into the office, most payors will allow reimbursement for the time spent administering the teaching dose

Kineret^®: At-Home Administration

Prescription Drug Benefit
If Kineret^® is covered through the prescription drug benefit of a plan, the pharmacy will most likely file a claim on behalf of the patient. Pharmacies typically require patient demographic information, insurance policy information, and details specific to the drug being purchased, including National Drug Code, quantity, strength, dosage, and supply (number of days).

Medical Benefit or Injectable Rider
If Kineret^® is covered under the medical benefit, the pharmacy may have the capability of submitting the claim electronically through its system. This happens when the pharmacy benefit and medical benefit are both administered by the same organization.

If the pharmacy is unable to submit the claim on behalf of the patient or the claim is rejected, the patient may be responsible for paying the pharmacy directly for Kineret^® and would then need to file a manual claim to the payor for reimbursement. The patient would need to contact the payor directly to obtain the appropriate claim form and submission requirements. These claim forms vary by payor, but may require patient demographic information and insurance information. Claims submission requirements can vary widely, as one payor may require billing with an HCPCS code, another may require the NDC number, and still another may have assigned a local code for Kineret^®.

When submitting claims manually versus electronically, you may consider including additional information such as a letter of medical necessity, medical records/history, or product information. This may also minimize processing delays and claim denials.

The Kineret^® Customer Call Center has reimbursement counselors available to assist with claim submission requirements and claim form completion. Reimbursement counselors are also available to assist in tracking the payment status of a claim submitted for Kineret^®. For assistance, please contact your reimbursement counselor by way of the Kineret^® Customer Call Center at 1-866-KINERET (1-866-546-3738).

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