Clinical criteria coding updates for specialty pharmacy are available
As a result of coding updates in the claims system, the claim system edits for the clinical criteria listed below will be revised. This will result in the review of claims for certain diagnoses before processing occurs to determine whether the service meets medical necessity criteria. As a result, these coding updates may result in a not medically necessary determination.
Effective May 1, 2019, we implemented coding updates in the claims system for the following clinical criteria listed below which may result in not medically necessary determinations for certain services.
- ING-CC-0073 – Alpha-1 Proteinase Inhibitor Therapy
Access the clinical criteria information on anthem.com.
July 2019 Anthem Provider News - Virginia