MedicaidPrior AuthHigh impact
New Policy Updates - Clinical Payment, Coding and Policy Changes
Aetna Better Health of Virginia·VA · Rheumatology, Gastroenterology, Dermatology +2 more·Reimbursement
Effective date
Oct 1, 2024
We identified it
Aug 13, 2026
Summary
Aetna Better Health of Virginia has established new clinical payment and coding policies effective October 1, 2024, with specific new restrictions on Infliximab (J1745, Q5103, Q5104, Q5109, Q5121) including daily dosage limits for pediatric patients aged 15-18 with plaque psoriasis or regional enteritis, cumulative limits over time for these same conditions, and visit frequency limits for adult ulcerative colitis patients 18+. Billing teams must implement these dosage and visit restrictions in their authorization and claims processing workflows to avoid claim denials.
Action Required
By October 1, 2024: Billing team and prior authorization staff must implement new dosage and visit limits for Infliximab codes in the authorization system and billing software. (1) Configure daily dosage limits for patients aged 15-18 years with diagnosis codes for plaque psoriasis (pediatric), pustular psoriasis, or regional enteritis (pediatric). (2) Configure cumulative dosage limits over time for patients aged 15-18 years with plaque psoriasis (pediatric) or regional enteritis (pediatric). (3) Configure cumulative visit limits over time for patients 18+ years with ulcerative colitis (adult). (4) Update prior authorization templates and clinical guidelines to reference these age-based and diagnosis-based restrictions. (5) Train clinical staff and billers on the new restrictions to ensure accurate coding and claim submission. (6) Coordinate with providers to ensure they are aware of dosage and visit limitations before October 1, 2024. Claims submitted without adherence to these limits will be subject to denial or downcode.