We’re expanding specialty pharmacy claim editing for Medicare Plus Blue

In support of correct coding and payment accuracy, we’ll begin applying additional edits for specialty pharmacy claims in March 2023 for our Medicare Plus Blue℠ members. These edits apply to claims processed under the medical benefit, not the pharmacy benefit.

They’ll address various coding inaccuracies, including, but not limited to:

• Invalid National Drug Codes, or NDCs
• Improper diagnosis codes
• Quantities
• Prior authorizations
• Wastage

These edits are supported by guidelines as approved by the Centers for Medicare & Medicaid Services and other nationally recognized governing bodies.