Drugs and biologic

Effective October 1, 2024, Anthem is enhancing its claims editing system to ensure that claims billed with pharmaceutical drug procedure codes are reported with the appropriate Federal Drug Administration (FDA) approved indicators for on- and off-label use.

These enhanced claim edits provide an opportunity for Anthem to evaluate submitted claims for drug quality, safety, and effectiveness. The enhancement is to have the claims deny if not billed with the FDA indicator for on-/off-label use.

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 questions about this notification, contact your contract manager or provider relationship management account representative.