Updated — Medicare Part B medical specialty drug authorization: Clarification regarding Prolia and Xgeva

This message was updated to show that authorization requests for Xgeva should be submitted using the brand name and not the generic name of the drug.

Part B specialty drugs Prolia® and Xgeva® have the same generic name, denosumab, and HCPCS code, J0897. Both drugs require authorization for Medicare Plus BlueSM PPO and BCN AdvantageSM members.

However, the system through which you request authorization varies as follows:

  • If you're administering Prolia, which is used to treat osteoporosis, request authorization through the NovoLogix® online tool.
  • If you're administering Xgeva, which is primarily used to treat bone metastases due to solid tumors, request authorization through the AIM ProviderPortalSM.

    • Note: Be sure to use the brand name when requesting Xgeva through the AIM ProviderPortal so AIM will know you are ordering the correct medication. Using the generic name, denosumab, can cause delays in the prior authorization process.

How to bill

Be sure to enter the following National Drug Code numbers on the claim, along with the HCPCS code J0897, to ensure appropriate and timely reimbursement.

  • Prolia - Enter NDC 55513071001
  • Xgeva - Enter NDC 55513073001

For Medicare Plus Blue and BCN Advantage, we require authorization for these medications for all outpatient sites of care when you bill the medications as a professional service or as an outpatient facility service and you bill as follows:

  • Electronically through an 837P transaction or on a professional CMS-1500 claim form

    • or

  • Electronically through an 837I transaction or using a UB04 claim form for a hospital outpatient type of bill 013x

Important reminder

You can quickly submit authorization requests through the NovoLogix online tool and through AIM Specialty Health.

  • NovoLogix: You can access NovoLogix through Provider Secured Services. It offers real-time status checks and immediate approvals for certain medications. Also note:
    • For Medicare Plus Blue, if you have a Type 1 (individual) NPI and you checked the "Medical Drug PA" box when you completed the Provider Secured Services Application form, you already have access to NovoLogix. If you didn't check that box, you can complete an Addendum P form to request access to NovoLogix and fax it to the number on the form.
    • For BCN Advantage, if you have access to Provider Secured Services, you already have access to enter authorization requests through NovoLogix.

    • If you need to request access to Provider Secured Services, complete the Provider Secured Services Application form and fax it to the number on the form.

  • AIM Specialty Health: You can submit authorizations through the AIM ProviderPortal or by calling AIM at 1-844-377-1278.

For information about registering for and accessing the AIM ProviderPortal, see the Frequently asked questions page on the AIM Specialty Health website*.

*Clicking this link means that you're leaving the Blue Cross Blue Shield of Michigan and Blue Care Network website. While we recommend this site, we're required to let you know we're not responsible for its content.

Posted: December 2019
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network