Enhanced claims edits system for drug quality checks

Summary:

• Effective November 1, 2024, Anthem plans to enhance its claims edits system to ensure that pharmaceutical drug procedure codes are aligned with FDA-approved indicators for on- and off-label use.
• These improvements will allow Anthem to evaluate submitted claims for drug quality, safety, and effectiveness more accurately.
• If a claim reimbursement decision requires review, care providers should follow the traditional claims dispute process and include relevant medical records.

Effective November 1, 2024, Anthem is enhancing its claims edits system to ensure that claims billed with pharmaceutical drug procedure codes are reported with the appropriate FDA-approved indicators for on- and off-label use.

These enhanced claim edits provide an opportunity for Anthem to evaluate submitted claims for drug quality, safety, and effectiveness.

If you believe a claim reimbursement decision should be reviewed, please follow the normal claims dispute process outlined in the provider manual and include medical records that clarify whether the indication was approved through the governing agencies. You will only need to submit the portion(s) of the medical record relevant to the drug provided.

If you have questions about this notification, contact your contract manager or provider relationship management account representative.

Together, we can work towards improved outcomes.