Enhanced claims edits for FDA-approved drug codes

Beginning with claims processing on or after December 1, 2024, we are enhancing our claims edits 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.

What are the purposes of the enhanced claim edits?

These enhanced claim edits offer an opportunity for us to evaluate submitted claims for drug quality, safety, and effectiveness. The enhancement is designed to deny claims if they are not billed with the FDA indicator for on- and off-label use.

What steps should I take if I disagree with a claim reimbursement decision?

If you believe a claim reimbursement decision should be reviewed, 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.

With your help, we can continually build towards a future of shared success. If you have questions, contact your provider relationship management account representative.