By Counterforce Health Team in HyperHEP (hepatitis B immune globulin) —

Coding That Helps Get HyperHEP (Hepatitis B Immune Globulin) Approved by Blue Cross Blue Shield in Ohio: ICD-10, HCPCS, and Medical Necessity

Answer Box: Getting HyperHEP Covered in Ohio

HyperHEP (hepatitis B immune globulin) requires prior authorization from Blue Cross Blue Shield in Ohio under the medical benefit. Use HCPCS code 90371 for billing, pair with exposure-specific ICD-10 codes (B19.1 for unspecified HBV exposure), and document clear medical necessity within CDC timing guidelines. First step today: Contact your provider to initiate prior authorization through Anthem's provider portal with complete exposure documentation and timing records.

Table of Contents

  1. Medical vs. Pharmacy Benefit Classification
  2. ICD-10 Coding for Hepatitis B Exposure
  3. HCPCS and Administration Codes
  4. Clean Prior Authorization Request
  5. Common Coding Pitfalls to Avoid
  6. Verification with Blue Cross Blue Shield
  7. Pre-Submission Audit Checklist
  8. Appeals Process in Ohio
  9. FAQ

Medical vs. Pharmacy Benefit Classification

HyperHEP (hepatitis B immune globulin) falls under the medical benefit with Blue Cross Blue Shield plans in Ohio, not the pharmacy benefit. This classification applies because HyperHEP is an injectable immunoglobulin product administered by healthcare providers in clinical settings.

Anthem's Specialty Drug List confirms that hepatitis B immune globulin products are classified as specialty injectables requiring provider administration. This means:

  • Prior authorization is required through medical management, not pharmacy benefits
  • Claims are processed under your medical coverage with applicable deductibles and coinsurance
  • Administration must occur in appropriate clinical settings (physician offices, hospitals, urgent care)
Note: Medical benefit classification means your provider handles the prior authorization process, not your retail pharmacy.

ICD-10 Coding for Hepatitis B Exposure

Proper ICD-10 coding is critical for establishing medical necessity for HyperHEP coverage. Use these codes based on the specific clinical scenario:

Primary Exposure Codes

  • B19.1 - Unspecified viral hepatitis B (most common for post-exposure prophylaxis)
  • B19.10 - Unspecified viral hepatitis B without hepatic coma
  • B16.9 - Acute hepatitis B without delta-agent and without hepatic coma

Specific Exposure Scenarios

  • B18.1 - Chronic viral hepatitis B without delta-agent (for known carrier exposure)
  • P00.2 - Newborn affected by maternal infectious diseases (perinatal exposure)
  • Z87.19 - Personal history of other diseases of the digestive system (if applicable)

Supporting Documentation Language

Your medical records should include specific terminology that supports the chosen ICD-10 code:

  • "Documented exposure to hepatitis B"
  • "Post-exposure prophylaxis indicated"
  • "Within recommended timeframe per CDC guidelines"
  • "Source patient HBsAg-positive" (when known)

According to Counterforce Health's analysis, proper documentation of exposure timing and source status significantly improves approval rates for hepatitis B immune globulin requests.

HCPCS and Administration Codes

Primary Product Code

HCPCS 90371 - Hepatitis B immune globulin (HBIG), human, for intramuscular use (per 1 mL)

This code covers the HyperHEP product itself. Billing is calculated per milliliter administered, so a 2 mL dose would be billed as 2 units of 90371.

Administration Code

CPT 96372 - Therapeutic, prophylactic, or diagnostic injection (intramuscular)

Bill this code separately for the administration service.

Dosing Calculations

HyperHEP is dosed at 0.06 mL/kg for adults and children, or 0.5 mL for infants and neonates. The product contains ≥220 IU/mL of hepatitis B immunoglobulin.

Example calculation for a 70 kg adult:

  • Dose needed: 70 kg × 0.06 mL/kg = 4.2 mL
  • Bill as: 5 units of HCPCS 90371 (round up to next whole mL)
  • Plus: 1 unit of CPT 96372 for administration

When Modifiers Apply

  • -25 modifier on the E/M code if evaluation and management occurs on the same day
  • -59 modifier may be needed if multiple injections are given
  • Verify modifier requirements with your specific Blue Cross Blue Shield plan

Clean Prior Authorization Request

A complete prior authorization request should include these elements in this order:

Clinical Information Section

  1. Patient demographics and Blue Cross Blue Shield member ID
  2. Primary diagnosis with appropriate ICD-10 code
  3. Exposure details: type, timing, and source information
  4. Medical necessity statement referencing CDC guidelines

Product Details Section

  1. Drug name: HyperHEP B (hepatitis B immune globulin)
  2. HCPCS code: 90371
  3. Requested quantity: calculated dose in mL
  4. Administration site: clinic/hospital location

Supporting Documentation

  • Exposure incident report (for occupational exposure)
  • Source patient HBsAg status (when available)
  • Patient's hepatitis B vaccination history
  • Timing documentation showing administration within recommended window
Tip: Counterforce Health helps providers create comprehensive prior authorization requests that address payer-specific requirements and improve approval rates.

Common Coding Pitfalls to Avoid

Unit Conversion Errors

Problem: Billing incorrect units of HCPCS 90371 Fix: Always bill per mL administered, rounding up to the next whole milliliter

Mismatched ICD-10 Codes

Problem: Using chronic hepatitis codes for acute exposure scenarios Fix: Use B19.1 (unspecified viral hepatitis B) for most post-exposure prophylaxis cases

Missing Timing Documentation

Problem: Failing to document administration within CDC-recommended timeframes Fix: Include specific dates of exposure and treatment in all documentation

Incorrect Benefit Category

Problem: Submitting to pharmacy benefit instead of medical benefit Fix: Ensure claims route through medical management with appropriate facility codes

Verification with Blue Cross Blue Shield

Before submitting your prior authorization request, verify these details with your specific Blue Cross Blue Shield plan:

Contact Information

  • Provider services: Use the phone number on the back of the patient's insurance card
  • Prior authorization department: Often a separate number for medical benefit requests

Plan-Specific Requirements

  1. Current prior authorization form (forms are updated regularly)
  2. Submission method: portal, fax, or mail
  3. Required attachments: clinical notes, lab results, incident reports
  4. Processing timeline: standard vs. expedited review options

Coverage Verification

  • Confirm HyperHEP is covered under the medical benefit
  • Check for any quantity limits or site-of-care restrictions
  • Verify if step therapy requirements apply

Pre-Submission Audit Checklist

Use this checklist before submitting your HyperHEP prior authorization:

✅ Documentation Review

  • Appropriate ICD-10 code selected and documented
  • HCPCS 90371 quantity matches calculated dose
  • CPT 96372 included for administration
  • Exposure timing clearly documented
  • Medical necessity statement included

✅ Clinical Requirements

  • CDC guidelines referenced for timing
  • Source patient status documented (when known)
  • Patient vaccination history included
  • Contraindications to vaccination noted (if applicable)

✅ Administrative Details

  • Current prior authorization form used
  • All required fields completed
  • Supporting documents attached
  • Submission method confirmed with payer

Appeals Process in Ohio

If your HyperHEP prior authorization is denied, Ohio residents have specific appeal rights:

Internal Appeals (First Level)

Timeline: 180 days from denial date Process: Submit written appeal to Blue Cross Blue Shield with additional clinical documentation Expected response: 30 days for standard review, 72 hours for expedited

External Review (Second Level)

Timeline: 180 days from final internal denial Process: Request external review through the Ohio Department of Insurance Contact: 1-800-686-1526 for assistance

The external review process in Ohio is binding and conducted by independent medical experts. Success rates vary, but thorough documentation of medical necessity significantly improves outcomes.

From our advocates: We've seen hepatitis B immune globulin denials successfully overturned when providers include detailed exposure documentation, CDC guideline references, and clear timing rationale. The key is demonstrating that the treatment meets established medical standards for post-exposure prophylaxis.

FAQ

Q: How long does Blue Cross Blue Shield prior authorization take for HyperHEP in Ohio? A: Standard reviews typically take 14-30 days. Expedited reviews for urgent medical situations can be completed within 72 hours.

Q: What if HyperHEP is not on my plan's formulary? A: Since HyperHEP is covered under the medical benefit, formulary status typically doesn't apply. Coverage is based on medical necessity rather than formulary placement.

Q: Can I request an expedited appeal for a HyperHEP denial? A: Yes, if the delay would seriously jeopardize your health. Contact Blue Cross Blue Shield immediately to request expedited review.

Q: Does step therapy apply to hepatitis B immune globulin? A: Step therapy rarely applies to post-exposure prophylaxis medications like HyperHEP, as they address acute medical situations with time-sensitive treatment requirements.

Q: What happens if I received HyperHEP in an emergency department? A: Emergency administration is typically covered, but you may need to submit documentation afterward. Keep all records and contact Blue Cross Blue Shield promptly.

Q: How do I find Ohio-specific Blue Cross Blue Shield forms? A: Visit the Anthem Ohio provider portal or contact provider services for current forms and submission requirements.

When navigating insurance coverage for specialty treatments like HyperHEP, having expert support can make the difference between approval and denial. Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals by analyzing denial letters, plan policies, and clinical notes to create compelling prior authorization requests that align with payer requirements.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage policies vary by plan and individual circumstances. Always consult with your healthcare provider and insurance company for specific coverage determinations. For assistance with insurance appeals in Ohio, contact the Ohio Department of Insurance at 1-800-686-1526.

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