Post service claims editing for certain medical/specialty drugs
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This policy describes BCBSRI's implementation of post-service claims editing for select medications under the medical and specialty benefit and applies to providers billing Medicare Advantage and Commercial products administered by BCBSRI/Prime Therapeutics.
No material clinical or coverage changes in this revision.
Coverage & Benefit Variability
Coverage and benefit variability
Benefits and coverage vary by member group or contract. Confirm applicable coverage in the member’s certificate or subscriber agreement.
ALL of the following
Coverage applies when
- Member's group/contract provides coverage for the service under the applicable member certificate or subscriber agreement.
Drug Coding and Post-Service Review Criteria
| See Commercial and Medicare Advantage drug lists for specific drugs subject to post service edits |
Provider Requirements and Actions
Prior authorization not required
Prior Authorization is not required for the medications listed in this policy.
Post-service claims editing — provider documentation required
Medications subject to post-service claims editing will be reviewed after claim submission for diagnosis appropriateness, dosing, units billed, and NDC match; providers must ensure submitted claims and supporting documentation substantiate these elements for review.
- Ensure claim diagnosis codes support the medical necessity of the drug (diagnosis appropriate for code).
- Document dosing and units administered so billed amounts can be validated against expected dosing.
- Include accurate NDC information on the claim to allow NDC match verification.
- Retain clinical records and administration documentation to support post-payment review requests.
Key Definitions
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.