AdministrativeMedicare AdvantageHoosier Healthwise, Healthy Indiana Plan, Hoosier Care Connect, and Indiana PathWays for AgingJune 1, 2025

Additional drug codes added to medical claims edit system

Background

We previously shared details about an enhancement to the medical claims editing system for pharmaceutical drug procedure codes. This improvement ensures that claims align with FDA‑approved or off‑label indications, based on the list of pharmaceutical compendia defined by CMS. This change aims to promote accuracy in claims and improve reimbursement efficiency.

Provider impact

Beginning with claims processing on or after July 1, 2025, we will introduce additional drug procedure codes into our system. Codes requiring preapproval or those tied to specific medical policies will not be affected by this update.

Note: A drug procedure code will not be approved if the diagnosis reported is not an approved indication.

If you would like your claim decision reviewed, follow the claims dispute process outlined in the provider manual. You must include relevant medical record details regarding the drug provided for faster resolution.

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

Thank you for your cooperation and commitment to improving member care.

Anthem Blue Cross and Blue Shield is the trade name of Anthem Insurance Companies, Inc., independent licensee of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

Providers who are contracted with Anthem Blue Cross and Blue Shield to serve Hoosier Healthwise, Healthy Indiana Plan, Hoosier Care Connect, and IN PathWays for Aging through an accountable care organization (ACO), participating medical group (PMG) or Independent Physician Association (IPA) are to follow guidelines and practices of the group. This includes but is not limited to authorization, covered benefits and services, and claims submittal. If you have questions, please contact your group administrator or your Anthem network representative.

INBCBS-CDCR-078830-25-CPN77148

PUBLICATIONS: June 2025 Provider Newsletter