Clinical Criteria coding updates for specialty pharmacy are available

Due to 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. 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.

 

Clinical Criteria Document Number	Clinical Criteria Name
ING-CC-0073	Alpha-1 Proteinase Inhibitor Therapy

 

You can go online to access the Clinical Criteria information.