Provider Information

Prior Authorization Request Services and Forms

Synagis/Respigam

Synagis is administered to children under the age of two that are at high risk for severe lower respiratory tract illness caused by the Respiratory Syncytial Virus (RSV).

South Dakota medical assistance recipients receiving this medication must be under the care/consultation of a neonatologist, pediatric pulmonologist, or pediatric cardiologist. These specialists must co-sign the authorization form.

This approval process is based on the American Academy of Pediatric (AAP) guidelines and is required prior to reimbursement.

• Synagis/Respigam Prior Authorization Form

Instructions:

Synagis and Respigam are covered by the South Dakota Medical Assistance Program when a child meets all of the following criteria:

• the medication has been prior authorized by the Department of Social Services/Medical Assistance;
• it has been recommended by a Neonatologist, Pediatric Pulmonologist, or Pediatric Cardiologist; and
• the child meets one of the following categories listed below:

1. Children under 6 months of age at the onset of the RSV season who were 35 weeks and less gestational age at birth.
   
   
2. Children under two years of age at the onset of the RSV season with evidence of ongoing lung disease such as bronchopulmonary dysplasia or cystic fibrosis requiring treatment with oral bronchodilators, supplemental oxygen, diuretics, or nebulized or inhaled medications to stabilize the disease in the last 6 months.
   
   
3. Children under two years of age at the onset of the RSV season with immunodeficiences that may make them more susceptible to severe lower respiratory tract disease related to RSV.
   
   
4. Any child under two years of age at the onset of the RSV season felt to be at high risk for significant lower respiratory tract illness related to RSV.

Billing Instructions: Physicians Office
Form: CMS 1500
Procedure Code: 90378
Rate of Payment: Changes have been made regarding the rate of payment and billing units of Synagis. Synagis is now reimbursed at the rate specified on the Physician Services fee schedule. Amounts must be billed in 50 milligram units.

Billing Instructions: Outpatient Hospital

Form: UB92
Revenue Code: 636 with Procedure Code 90378
Rate of Payment: Hospital’s Outpatient Rate
Prior Authorization Number: Enter this number in Block 63A. The same authorization number may be used for the entire series.

Home Health

Procedure Code: 99506