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DFEC clarifies reimbursement policies on physician dispensed medications

by
Optum Workers' Comp
| May 29, 2018

A recent FECA Circular – No. 18-6 – provides clarification on existing policies around the qualification and reimbursement of physician dispensed medications for federal workers’ compensation claims. Effective June 1, 2018, the circular is aimed at ensuring that certain physician dispensed medications do not bypass controls previously implemented in 2012 by DFEC.

As part of the circular, DFEC will continue to authorize and pay for certain established “J codes” if these medications are properly administered and billed. To expand on the set of established “J codes,” you must submit an additional specific set of medications with an NDC and the days’ supply. These will be subject to prior authorization. As part of the reimbursement structure, DFEC will rely on the specific HCPCS J code to determine whether a medication dispensed and billed is a drug “that ordinarily cannot be self-administered” and if it will be authorized and paid.

Additionally, DFEC indicated a set of medications in the circular which ordinarily can be self-administered would not need to be administered by a physician and in turn would not be generally authorized and paid. These examples include certain ointments/lotions, patches, combination medication kits and other listed oral medications. Prior authorization for these medications may be requested by utilizing the Unspecified J Code Authorization Request available on the DFEC Web Bill Processing website.

The FECA Circular can be found here.

Should you have any questions on this or other legislative or regulatory topics, please contact our Government Affairs Team at AskGovtAffairs@optum.com


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