New claims edits system enhances drug safety

Beginning with claims processing on or after February 1, 2025, (90-day MAC notice required) HealthKeepers, Inc. is enhancing its claims edits system to ensure claims billed with pharmaceutical drug procedure codes are reported with an FDA-approved indication or an approved off-label indication on the claim.

These enhanced claim edits provide an opportunity for HealthKeepers, Inc. to evaluate submitted claims for drug quality, safety, and effectiveness. The enhancement is to have the claims deny if the diagnosis reported is not one that is an FDA-approved indication or an approved off-label indication for the drug procedure code.

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 that is relevant to the drug provided.

If you have any questions about this communication, contact Anthem HealthKeepers Plus Provider Services at 800-901-0020.