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

Work With Your Doctor to Get HyperHEP (Hepatitis B Immune Globulin) Approved by Humana in New Jersey

Answer Box: Getting HyperHEP Approved by Humana in New Jersey

HyperHEP (hepatitis B immune globulin) requires prior authorization from Humana Medicare Advantage plans and may be covered under Medicare Part B (not Part D) when given for post-exposure prophylaxis in clinical settings. Your fastest path: Have your doctor submit a prior authorization request through Humana's provider portal with clinical documentation of hepatitis B exposure within 7 days. Start today: Call your prescriber to schedule an urgent visit and request they check whether HyperHEP should be billed under Part B or Part D for your specific situation.

Three-step workflow: 1) Visit your doctor with exposure timeline and risk factors documented, 2) Provider submits PA with medical necessity letter citing CDC guidelines, 3) If denied, file peer-to-peer review at 866-488-5995, then formal appeal within 65 days.

Table of Contents

Set Your Goal: Understanding HyperHEP Approval Requirements

When you need HyperHEP (hepatitis B immune globulin) for post-exposure prophylaxis, timing is everything. The CDC recommends HBIG administration within 7 days of exposure, with maximum effectiveness in the first 24-48 hours.

Your partnership with your healthcare provider is crucial because Humana requires prior authorization for HyperHEP as a high-cost specialty medication. However, there's an important distinction: if you're receiving HyperHEP in a clinic, emergency room, or hospital setting for post-exposure prophylaxis, it may be covered under Medicare Part B rather than Part D.

Coverage at a Glance
Requirement What It Means Where to Find It
Prior Authorization Required for most Humana MA plans Provider portal PA search
Medical Necessity Must document exposure and timing CDC post-exposure guidelines
Part B vs Part D Depends on setting and indication Humana vaccine coverage guide
Appeals Deadline 65 days from denial notice Humana appeals process

Your goal: Work with your provider to submit a complete, well-documented prior authorization that demonstrates medical necessity and appropriate timing for HyperHEP administration.

Visit Preparation: Documenting Your Case

Before your appointment, gather detailed information about your hepatitis B exposure. Your provider needs specific details to build a strong case for medical necessity.

Exposure Timeline Documentation:

  • Exact date and time of exposure
  • Type of exposure (needlestick, sexual contact, blood splash to mucous membranes)
  • Source person's hepatitis B status (if known)
  • Your hepatitis B vaccination history
  • Any previous hepatitis B testing results

Symptom and Risk Factor Notes:

  • Current symptoms (if any)
  • Immunocompromised status
  • Pregnancy status
  • Occupation (healthcare worker, first responder)
  • Other risk factors that increase transmission likelihood

Treatment History:

  • Previous hepatitis B vaccinations and dates
  • Any prior HBIG administration
  • Recent laboratory results (anti-HBs levels if available)
  • Contraindications to hepatitis B vaccine
Tip: Bring your vaccination records or ask your provider to check the New Jersey Immunization Information System (NJIIS) for your hepatitis B vaccination history.

Building Your Evidence Kit

Your provider will need comprehensive documentation to support the prior authorization request. Help them gather this evidence efficiently.

Laboratory and Diagnostic Evidence:

  • Source person's HBsAg test results (if available)
  • Your baseline anti-HBs levels
  • Complete hepatitis panel if indicated
  • Documentation of exposure circumstances (incident reports, etc.)

Published Guidelines and References: Your provider should reference established guidelines in the medical necessity letter:

Medication History Summary:

  • Complete list of current medications
  • Previous adverse reactions to immune globulin products
  • Contraindications to alternative treatments

Counterforce Health specializes in helping patients and providers navigate complex prior authorization requirements by analyzing denial patterns and crafting targeted, evidence-backed appeals that address specific payer criteria.

Medical Necessity Letter Structure

Your provider's medical necessity letter is the cornerstone of your prior authorization request. A well-structured letter should include these key elements:

1. Clinical Problem Statement

  • Clear diagnosis (exposure to hepatitis B)
  • ICD-10 code (Z20.5 - Contact with and exposure to viral hepatitis)
  • Specific exposure circumstances and timeline

2. Treatment Rationale

  • Why HyperHEP is medically necessary
  • Timing requirements per CDC guidelines
  • Patient-specific risk factors

3. Prior Treatments and Contraindications

  • Vaccination status and response
  • Why vaccine alone is insufficient
  • Any contraindications to alternative approaches

4. Clinical References

  • CDC post-exposure prophylaxis guidelines
  • Relevant medical literature
  • Professional society recommendations

5. Dosing and Administration Plan

  • Specific HyperHEP dose (0.06 mL/kg IM)
  • Administration timeline
  • Follow-up monitoring plan
Clinician Corner: Include specific details about the exposure risk assessment and why the 7-day window for HBIG effectiveness makes this treatment urgent. Reference the CDC's recommendation that HBIG plus hepatitis B vaccine provides optimal protection for susceptible individuals exposed to HBsAg-positive sources.

Peer-to-Peer Review Support

If Humana's initial review raises questions, your provider can request a peer-to-peer review with a Humana medical director. This physician-to-physician discussion often resolves coverage issues more efficiently than formal appeals.

How to Support Your Provider:

  • Offer flexible scheduling for urgent peer-to-peer calls
  • Provide a concise case summary highlighting key points
  • Be available to clarify exposure details if needed

Provider Peer-to-Peer Process: Your doctor should call 866-488-5995 to request immediate physician discussion. They should emphasize:

  • Time-sensitive nature of post-exposure prophylaxis
  • Specific exposure circumstances
  • Clinical guidelines supporting HBIG use
  • Patient-specific risk factors

What to Expect: Peer-to-peer reviews typically occur within 24-48 hours of the request. The Humana medical director will review your case with your provider and may approve coverage immediately if medical necessity is clearly established.

After Your Visit: Next Steps

Document Everything:

  • Save copies of all forms submitted
  • Keep your provider's medical necessity letter
  • Document submission dates and confirmation numbers
  • Save any correspondence from Humana

Portal Communication: Use your patient portal to:

  • Request copies of clinical notes from your visit
  • Follow up on prior authorization status
  • Communicate any new symptoms or concerns

Timeline Tracking:

  • Prior authorization decisions: typically within 1 business day for electronic submissions
  • Standard appeals: 30 days for pre-service, 60 days for post-service
  • Expedited appeals: as soon as possible if delay could cause serious harm

Respectful Persistence Strategy

Update Cadence:

  • Check prior authorization status every 2-3 business days
  • Contact your provider's office weekly if no response
  • Document all phone calls and reference numbers

Escalation Steps:

  1. Provider office follow-up with Humana
  2. Request peer-to-peer review if initial PA denied
  3. File formal appeal within 65 days
  4. Consider New Jersey external review if internal appeals exhausted

Professional Communication:

  • Always be courteous with Humana representatives
  • Ask for reference numbers for all interactions
  • Request supervisors if initial representatives cannot help
  • Keep detailed records of all conversations

Appeals Process in New Jersey

If Humana denies your HyperHEP prior authorization, New Jersey offers robust appeal rights through multiple levels.

Internal Appeals with Humana:

  • Timeline: 65 days from denial notice
  • Method: Availity Essentials portal or mail/fax
  • Required documents: Denial notice, original claim, clinical records
  • Decision timeline: 30 days for pre-service, 60 days for post-service

New Jersey External Review (IHCAP): After exhausting Humana's internal appeals, you can file an external review through New Jersey's Independent Health Care Appeals Program, administered by Maximus Federal Services.

IHCAP Process:

  • Filing deadline: 4 months (120 days) from final internal denial
  • Submission: Electronic via NJIHCAP.Maximus.com or mail
  • Decision timeline: 45 days for standard, 48 hours for expedited
  • Cost: Fee required (verify current amount with DOBI)
  • Binding: Decision is binding on Humana
From Our Advocates: We've seen cases where patients successfully obtained HyperHEP coverage through New Jersey's external review process by emphasizing the time-sensitive nature of post-exposure prophylaxis and including detailed exposure documentation. The key was demonstrating that the 7-day treatment window made this medically urgent, not elective.

Common Denial Reasons & Solutions

Denial Reason How to Overturn Required Documentation
"Not medically necessary" Emphasize CDC guidelines and exposure timeline Incident report, source HBsAg status, exposure details
"Outside treatment window" Document that 7-day window still applies Exposure date verification, clinical urgency letter
"Vaccination adequate" Explain why passive immunity needed Anti-HBs levels, vaccination response history
"Part B vs Part D coverage" Request coverage determination Administration setting, clinical indication

Part B vs Part D Determination: If Humana questions whether HyperHEP should be covered under Part B or Part D, request a formal coverage determination. Post-exposure prophylaxis administered in clinical settings typically qualifies for Part B coverage.

Costs and Financial Assistance

HyperHEP Pricing:

  • Retail cost ranges from $129-$900+ per vial depending on strength
  • Medicare Part B typically covers 80% after deductible
  • Part D coverage varies by plan formulary tier

Financial Assistance Options:

  • Grifols (manufacturer) patient assistance programs
  • State vaccine assistance programs through New Jersey Department of Health
  • Hospital charity care programs for emergency treatment
  • Medicare Extra Help for prescription drug costs

Coverage Optimization: Work with Counterforce Health to identify the most effective appeal strategy based on your specific Humana plan's denial patterns and coverage policies.

FAQ

How long does Humana prior authorization take for HyperHEP in New Jersey? Electronic submissions typically receive decisions within 1 business day. Standard paper submissions may take up to 72 hours.

What if HyperHEP is not on Humana's formulary? Request a formulary exception with medical necessity documentation. Emphasize that no therapeutic alternatives exist for passive hepatitis B immunity.

Can I request an expedited appeal if treatment is urgent? Yes, expedited appeals are available when delays could cause serious harm to health. Post-exposure prophylaxis timing may qualify for expedited review.

Does step therapy apply to HyperHEP? Step therapy typically doesn't apply to immune globulins used for post-exposure prophylaxis, as no lower-cost alternatives provide equivalent passive immunity.

What happens if I received HyperHEP before authorization? You can file a post-service appeal with documentation of the emergency nature of treatment and medical necessity.

How do I know if my exposure qualifies for HyperHEP? Exposures to HBsAg-positive sources through percutaneous injury, mucous membrane contact, or sexual contact typically qualify. Your provider will assess your specific risk factors.

Sources & Further Reading

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 decisions. Coverage policies and requirements may change; verify current information with official sources.

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