Clotting Factors (CPB 0131, reviewed 2026-04-23)

IMMEDIATE: Billing team must implement mandatory precertification workflow for all clotting factor prescriptions. (1) Update billing system to flag ALL clotting factor claims requiring prior authorization through Aetna's Special Case Precertification Unit at (855) 888-9046 before claim submission. (2) Verify provider specialty requirement—all clotting factors must be prescribed by or in consultation with a hematologist; deny claims from non-hematology providers without hematology consultation documentation. (3) Add precertification checklist to encounter forms requiring documentation of: disease type/severity (mild/moderate/severe for hemophilia A), inhibitor titer levels (for inhibitor-containing conditions), prior treatment history (especially for Jivi eligibility—age 7+ and prior Factor VIII use), and desmopressin failure/contraindication (for applicable indications). (4) Ensure continuation-of-therapy authorizations document evidence of clinical benefit (reduced bleed frequency/severity). (5) For Hemlibra (emicizumab) specifically, verify discontinuation of Factor VIII prophylaxis after first week and confirm no gene therapy history. (6) Train billing and front desk staff on specialty requirement and precertification mandate. Failure to obtain precertification will result in claim denials.