CommercialCoverageHigh impact
Infusion Care - Site of Service Policy Update
EmblemHealth·Oncology, Neurology, Rheumatology +4 more·Provider News
Effective date
Jul 15, 2024
We identified it
Jun 20, 2026
Summary
EmblemHealth and ConnectiCare are expanding their Infusion Site of Service policy effective July 15, 2024, removing age restrictions so pediatric patients up to age 21 must receive infusions in non-hospital settings when medically appropriate. The policy adds 168 medications to the site-of-service requirements but excludes Qalsody (J1304) and Spinraza (J2326).
Action Required
By July 15, 2024: Billing team must update prior authorization and site-of-service verification procedures to include pediatric patients up to age 21 for infusion services. Update billing system to flag infusion claims for patients under 21 to ensure medical appropriateness documentation for non-hospital settings. Exclude J1304 (Qalsody) and J2326 (Spinraza) from site-of-service restrictions. Review the 168 additional medications list from EmblemHealth/ConnectiCare announcements and update encounter forms accordingly.