Blog

Zerbaxa Prior Authorization: What You Need to Know?

If you’ve ever tried to get prior authorization (PA) for a medication like Zerbaxa (ceftolozane/tazobactam), you know just how complicated—and time-sensitive—it can be, especially when treating serious infections. For healthcare providers, it’s a balancing act: saving time while ensuring your patient gets access to the critical medications they need.

The good news? You don’t have to figure it out alone. By following the right steps and submitting all the required documentation, you can approach this process with confidence. This guide will walk you through each stage of obtaining prior authorization for Zerbaxa, making the experience smoother and less stressful. Let’s get started!

Understanding Insurance Company Policies

Insurance companies like UnitedHealthcare, Cigna, Aetna, and Blue Cross Blue Shield have unique rules regarding Zerbaxa. These include medical vs. pharmacy benefits, step therapy requirements, and portal submissions. Some plans cover Zerbaxa under the medical benefit or the pharmacy benefit. Insurers often require evidence of other antibiotics being tried first or deemed inappropriate.

Why Is Prior Authorization Needed for Zerbaxa?

Zerbaxa is a combination antibiotic used to treat life-threatening infections like urinary tract infections, intra-abdominal infections, and hospital-acquired bacterial pneumonia. Insurers require prior authorization to ensure the diagnosis matches approved indications, the infection is serious due to resistant bacteria, other antibiotics have failed, and Zerbaxa is being used appropriately. This process ensures that Zerbaxa is prescribed only when absolutely necessary and justified, ensuring that it is used appropriately and in line with FDA guidelines or insurer policies.

Step-by-Step Guide to Zerbaxa Prior Authorization

Step 1: Collect All Required Documentation

A complete submission makes all the difference. Here’s what you’ll need:

• Prescriber’s Order:
  Include the diagnosis, dosage, frequency, and planned treatment duration.
• Clinical Notes:
  Document the patient’s infection history, results from cultures/sensitivity tests, and why Zerbaxa is necessary.
• Step Therapy Records:
  Provide evidence that other antibiotics failed, weren’t tolerated, or were inappropriate.
• Diagnostic Results:
  Relevant lab reports, such as urine cultures, bloodwork, or imaging studies, to support your diagnosis.
• Insurance PA Form:
  Download the insurer-specific prior authorization form, usually available online.

Step 2: Confirm Accurate ICD-10 and CPT Codes

Using the correct codes can make or break your submission.

Step 3: Submit the Prior Authorization Request

Once you have everything ready, submit the request using the insurer’s preferred method:

• Online Portals: Most insurers use platforms like CoverMyMeds or their proprietary submission systems.
• Fax or Mail: While slower, these methods are still accepted by some insurers.
• EHR Systems: Some electronic health records systems are integrated with payer platforms for direct submission.

Pro Tip: Double-check that all documentation is included and accurate. Missing details are a leading cause of PA denials.

Step 4: Follow Up Regularly

Don’t let your request sit in limbo! After submitting the PA:

• Confirm the insurer received your request. A quick call can save days of waiting.
• Check for updates regularly. Response times vary but typically range from 48 hours to 14 days.
• Be ready to provide additional documentation if requested.

Step 5: Handle Approvals or Denials

If approved:

• Verify the patient’s copay or out-of-pocket costs and confirm the treatment timeline.
• Check if the authorization has an expiration date or requires renewal.

If denied:

• Read the denial letter carefully. Insurers typically explain the reason (e.g., missing documentation or unmet criteria).
• Submit an appeal with updated clinical evidence, like additional diagnostic reports or a more detailed letter of medical necessity.

ICD and CPT Codes Explained

ICD-10 Codes (Diagnosis):

• N39.0: Urinary tract infection, site not specified
• K65.2: Peritonitis (complicated intra-abdominal infection)
• J15.0: Pneumonia due to Klebsiella pneumoniae

CPT Codes (Procedure/Administration):

• Zerbaxa administration codes depend on the healthcare setting:
  • 96365: IV infusion, first hour
  • J3490: Unclassified drugs (used for Zerbaxa if no specific code is provided)

Frequently Asked Questions (FAQs)

1. Why is prior authorization required for Zerbaxa?
Due to its high cost and targeted indications, insurers require PAs to ensure it’s used appropriately and only when necessary.

2. How long does it take to process a PA for Zerbaxa?
Processing times vary but generally range from 5 to 14 business days. Urgent cases may be expedited.

3. What if my PA request is denied?
You can appeal. Most denials result from incomplete documentation or unmet criteria, which can often be resolved by submitting additional evidence.

4. Can I check my PA status online?
Yes, many insurers allow you to track the status via platforms like CoverMyMeds or their own online portals.

5. Does prior authorization for Zerbaxa need renewal?
In many cases, yes. Insurers may require reauthorization, especially if the treatment duration extends beyond the initial approval period.

What Did We Learn?

• Documentation is critical. The more thorough your submission, the smoother the process will be.
• ICD-10 and CPT codes matter. Ensure they align with the patient’s diagnosis and treatment plan.
• Follow-up is essential. Proactive communication with insurers prevents delays.
• Appeals work. Many initial denials can be overturned with additional evidence or clarification.

Staffingly, Inc. offers a comprehensive solution for healthcare providers dealing with the Zerbaxa prior authorization process. They specialize in prior authorization, insurance verification, and revenue cycle management, ensuring a hassle-free experience for healthcare providers. With 24/7 support from experts, they can save up to 70% on costs and focus on patient care, allowing them to save more on their services.

Disclaimer

The information in our posts is meant to inform and educate both healthcare providers and readers seeking a better understanding of healthcare processes. However, it is not a substitute for professional advice. Insurance requirements, policies, and approval processes can vary widely and change over time. For accurate guidance, healthcare providers should consult directly with insurers or use professional resources, while patients should reach out to their insurance providers or healthcare professionals for advice specific to their situation.

This content does not establish any patient-caregiver or client-service relationship. Staffingly, Inc. assumes no liability for actions taken based on information provided in these posts.

For tailored support and professional services,

please contact Staffingly, Inc. at (800) 489-5877

Email : support@staffingly.com.