Effective March 1, 2023, we will conduct post-service medical claims reviews of certain drugs to ensure adherence to Food and Drug Administration (FDA)-approved prescribing guidelines. We will deny claims for these drugs that are billed at a frequency that exceeds the dosing guidelines, unless there is an authorization on file indicating an approval of the more frequent dosing. Our review will typically occur 2-10 days after the claim submission.
If we deny a claim because it doesn’t meet the FDA prescribing guidelines, the provider is responsible for the resulting costs.
The drugs and CPT® codes that are included in this post-service review are:
The Medicare Advantage Medications/Drugs (Outpatient/Part B) Coverage Summary references these drugs and the drug policy used as the basis for the dosage and frequency review. Analysis has shown that these drugs are being administered at a frequency that exceeds the FDA prescribing guidelines as outlined in the drug policy.
For more information or answers to specific questions, call the Provider Services phone number on the back of the member ID card.