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 June 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.