ClaimsXtenTM New Specialty Pharmacy Rule: Notification of Postponement

Posted April 18, 2016 (Updated June 1, 2016)

On April 18, 2016, BCBSIL announced the upcoming implementation of the ClaimsXten Speciality Pharmacy Rule for dates of service on or after July 18, 2016. This notification is to announce that the implementation of this new rule has been postponed and the rule now will apply to professional and outpatient facility claims with dates of service on or after Aug. 15, 2016, for all lines of business except Federal Employee Program (FEP). FEP will implement this new rule Sept. 26, 2016. The new rule is summarized below: 

The Specialty Pharmacy Knowledge Pack rule will audit professional and outpatient facility claims involving specialty pharmaceuticals with the following parameters: 

  • HCPCS J-code and diagnosis as defined by the U.S. Food and Drug Administration (FDA) labeling
  • HCPCS J-code and maximum billable units
  • HCPCS J-code and age
  • HCPCS J-code and gender
  • HCPCS J-code and place of service
  • HCPCS J-code with any combination of the elements listed above

This rule will deny claim lines found not payable according to guidelines provided by the FDA and National Comprehensive Cancer Network.

To help determine how coding combinations on a particular claim may be evaluated during the claim adjudication process, you may continue to utilize Clear Claim ConnectionTM (C3). C3 is a free, online reference tool that mirrors the logic behind BCBSIL’s code-auditing software. For more information on C3 and ClaimsXten, including answers to frequently asked questions, refer to the Clear Claim Connection page. Additional information also may be included in upcoming issues of the Blue Review

ClaimsXten and Clear Claim Connection are trademarks of McKesson Information Solutions, Inc., an independent third party vendor that is solely responsible for its products and services. 

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