How to Get HyperHEP B (Hepatitis B Immune Globulin) Covered by Cigna in North Carolina: Prior Authorization Guide and Appeal Process
Answer Box: Getting HyperHEP B Covered by Cigna in North Carolina
HyperHEP B (hepatitis B immune globulin) requires prior authorization from Cigna for post-exposure prophylaxis. In North Carolina, submit PA requests through Cigna's provider portal with exposure documentation, patient immunity status, and CDC-compliant timing (within 24 hours for needlestick, 7 days for sexual exposure). If denied, appeal internally within 180 days, then request external review through North Carolina's Smart NC program within 120 days. First step: Gather exposure incident report, source HBsAg status, and patient vaccination history before submitting PA request.
Table of Contents
- Coverage Requirements at a Glance
- Step-by-Step: Fastest Path to Approval
- Medical Necessity Documentation
- Coding and Billing Essentials
- Common Denial Reasons and Solutions
- Appeals Process in North Carolina
- Cost-Saving Options
- When to Contact North Carolina Regulators
- Frequently Asked Questions
Coverage Requirements at a Glance
| Requirement | Details | Documentation Needed | Source |
|---|---|---|---|
| Prior Authorization | Required for all HBIG products | Provider portal submission | Cigna PA Requirements |
| Medical Necessity | CDC-compliant post-exposure prophylaxis | Exposure report, timing, source HBsAg status | CDC Guidelines |
| Billing Code | HCPCS 90371 (per mL administered) | Weight-based dosing calculation | HCPCS Code Details |
| ICD-10 Codes | B19.1 (acute exposure), Z20.6 (contact) | Incident report with exposure type | ICD-10 Guidelines |
| Timing Window | Within 24-48 hours of exposure | Timestamped incident documentation | FDA Labeling |
Step-by-Step: Fastest Path to Approval
1. Document the Exposure Immediately
Who: Healthcare provider or occupational health What: Record exposure date/time, nature (needlestick, sexual, perinatal), source patient HBsAg status if known Timeline: Within hours of exposure
2. Assess Patient Immunity Status
Who: Ordering provider What: Review HBV vaccination history, check anti-HBs titers if available Documents: Vaccination records, lab results Note: Non-immune or unknown immunity patients qualify for HBIG
3. Calculate Proper Dosing
Who: Provider or pharmacy What: 0.06 mL/kg for adults/children; 0.5 mL for infants Example: 70 kg adult = 4.2 mL (bill as 5 units of HCPCS 90371)
4. Submit Prior Authorization
Who: Provider office Where: Cigna provider portal or CoverMyMeds Include: Patient ID, exposure details, ICD-10 codes, HCPCS quantities Timeline: Request expedited review for urgent cases (72-hour response)
5. Administer if Approved
Who: Licensed healthcare provider How: Intramuscular injection only Billing: HCPCS 90371 + CPT 96372 (administration)
6. Monitor for Approval/Denial
Timeline: Standard PA decisions within 3-5 business days Action: If denied, proceed to internal appeal immediately
7. File Appeal if Necessary
Who: Provider or patient Timeline: Within 180 days of denial notice Where: Cigna appeals department or North Carolina Smart NC for external review
Medical Necessity Documentation
Clinician Corner: Building a Strong PA Request
Your medical necessity letter should include these key elements:
Clinical Rationale:
- Document specific exposure type and timing
- Include CDC post-exposure prophylaxis guidelines reference
- Note patient's HBV immunity status (vaccination history, anti-HBs levels)
- Justify dosing calculation based on patient weight
Required Documentation:
- Incident report with timestamp
- Source patient HBsAg results (if available)
- Patient vaccination records
- Weight for dosing calculation
- ICD-10 codes matching exposure scenario
Sample Necessity Statement: "Patient requires HyperHEP B following confirmed needlestick exposure to HBsAg-positive blood on [date], within CDC-recommended 24-hour window. Patient immunity status unknown/inadequate based on vaccination history. Dosing calculated at 0.06 mL/kg per FDA labeling and CDC guidelines to prevent chronic HBV infection."
Tip: Emergency departments can often administer first and seek retroactive authorization, but document the emergency nature clearly.
Coding and Billing Essentials
Medical vs. Pharmacy Benefit
HyperHEP B is typically covered under the medical benefit when administered in clinical settings. Cigna processes these claims through their medical benefit rather than pharmacy benefit due to the injection administration requirement.
HCPCS Code 90371 Billing
- Code: 90371 - Hepatitis B immune globulin, human, for intramuscular use, per 1 mL
- Units: Bill per mL administered (round up to next whole mL)
- Administration: CPT 96372 for intramuscular injection
ICD-10 Code Selection by Scenario
| Exposure Type | Primary ICD-10 | Secondary Options | Notes |
|---|---|---|---|
| Needlestick/Occupational | B19.1 | B16.9, Z20.6 | Pair with incident report |
| Sexual Contact | Z20.6 | B19.1 | Document high-risk exposure |
| Perinatal | P00.2 | Z11.59 | Maternal HBsAg screening |
Dosing and Units Calculation
| Patient Weight | Dose Required | Billable Units (90371) |
|---|---|---|
| 50 kg adult | 3.0 mL | 3 units |
| 70 kg adult | 4.2 mL | 5 units |
| 90 kg adult | 5.4 mL | 6 units |
| Infant | 0.5 mL | 1 unit |
Common Denial Reasons and Solutions
| Denial Reason | How to Overturn | Documents to Include |
|---|---|---|
| "Outside timing window" | Provide timestamped incident report | CDC guidelines on acceptable windows |
| "Patient immunity not assessed" | Submit vaccination records and titers | Lab results showing non-immunity |
| "Incorrect dosing" | Recalculate based on weight | Weight documentation and FDA labeling |
| "Non-formulary" | Request formulary exception | Clinical rationale for HyperHEP B specifically |
| "Not medically necessary" | Strengthen exposure documentation | Source patient HBsAg results, incident details |
Appeals Process in North Carolina
Internal Appeals with Cigna
Level 1 Internal Appeal:
- Timeline: File within 180 days of denial
- Response time: 30 days standard, 72 hours expedited
- How to file: Cigna member portal, mail, or fax
- Include: Denial letter, medical records, prescriber letter
Level 2 Internal Appeal:
- Timeline: File within 60 days of Level 1 denial
- Response time: 30 days standard
- Additional option: Request peer-to-peer review with medical director
External Review Through Smart NC
If Cigna upholds the denial after internal appeals, North Carolina residents can request external review through the state's Smart NC program.
Key Benefits:
- Independent medical review
- No cost to patient
- Binding decision on insurer
- Fast turnaround for urgent cases
How to File:
- Call Smart NC at 1-855-408-1212
- Submit external review request form
- Include all medical records and denial letters
- Smart NC assigns Independent Review Organization (IRO)
Timelines:
- Standard review: 45 days from submission
- Expedited review: 72 hours for urgent cases
- Ultra-expedited: 24 hours for immediate medical needs
Note: Smart NC staff can help you complete the external review application and gather supporting documentation at no charge.
When Counterforce Health helps patients navigate these appeals, we often see success when the clinical documentation clearly establishes the exposure timeline and medical necessity according to CDC guidelines. The platform's ability to match payer-specific requirements with evidence-backed appeals has proven particularly effective for time-sensitive cases like HyperHEP B post-exposure prophylaxis.
Cost-Saving Options
Manufacturer Support
- Grifols Patient Assistance: Contact manufacturer directly for copay assistance programs
- Eligibility: Varies by insurance status and income
Cigna-Specific Programs
- Specialty pharmacy: May offer lower copays through Accredo
- Prior authorization: Can reduce out-of-pocket costs vs. paying cash
Emergency Situations
- Hospital financial assistance: Many hospitals offer charity care programs
- State emergency funds: North Carolina may have emergency medication funds
When to Contact North Carolina Regulators
Contact the North Carolina Department of Insurance if:
- Cigna fails to respond to appeals within required timeframes
- You believe Cigna violated state insurance laws
- Smart NC external review process is delayed beyond statutory limits
North Carolina Department of Insurance
- Phone: 1-855-408-1212 (Smart NC)
- Website: ncdoi.gov
- Complaint filing: Available online or by phone
Frequently Asked Questions
How long does Cigna prior authorization take for HyperHEP B in North Carolina? Standard PA requests receive responses within 3-5 business days. Expedited requests for urgent post-exposure cases can be processed within 72 hours.
What if HyperHEP B is not on Cigna's formulary? Request a formulary exception through Cigna's prior authorization process. Include clinical rationale for why HyperHEP B is medically necessary over alternatives.
Can I get an expedited appeal if my PA is denied? Yes, if the delay would seriously jeopardize your health. Both Cigna internal appeals and North Carolina external reviews offer expedited pathways.
Does step therapy apply to hepatitis B immune globulin? Step therapy typically doesn't apply to post-exposure prophylaxis due to the time-sensitive nature, but verify with your specific Cigna plan.
What happens if I miss the 24-hour window for post-exposure treatment? HBIG can still be effective up to 7 days post-exposure for some scenarios. Include clinical justification for delayed administration in your PA request.
Can I appeal a Cigna denial if I live in North Carolina but have coverage through an employer plan? Self-funded employer plans may not be subject to North Carolina's external review process. Check with Smart NC to determine eligibility.
How much does HyperHEP B cost without insurance? Retail prices range from approximately $129 for small vials to $900+ for larger doses, depending on the facility and dose required.
What documentation do I need to gather before starting the appeal process? Collect your insurance card, denial letters, medical records, incident reports, vaccination history, and any lab results showing HBsAg status or immunity levels.
From our advocates: We've seen cases where patients initially faced denials for timing issues, but successful appeals included detailed incident reports with exact timestamps and CDC guideline references. The key is thorough documentation of the exposure event and clear medical necessity justification.
For complex cases involving multiple denials or unusual circumstances, Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals. The platform analyzes denial letters, plan policies, and clinical notes to identify specific denial reasons and craft point-by-point rebuttals aligned with each payer's requirements.
Sources and Further Reading
- Cigna Prior Authorization Requirements
- North Carolina Smart NC External Review Program
- CDC Hepatitis B Post-Exposure Guidelines
- HyperHEP B Prescribing Information
- HCPCS Code 90371 Details
- FDA HyperHEP B Labeling
Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Always consult with your healthcare provider and insurance plan for specific coverage details. Insurance policies and state regulations may change; verify current requirements with official sources.
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