Drug and Biologic Edits

We announced the implementation of new drug and biologic edits in the February 2024 issue of Provider News. These drug and biologic edits complement other medication management strategies and help support appropriate medication use and accurate claims submission.

Receiving accurate claims is important for patient safety programs such as identifying drug disease interactions, and the correct payment for provided services. The drug and biologic edits also align with the medical policy criteria and support appropriate ongoing medication use.

Examples of scenarios that may encounter a drug and biologic edit include:

• Billing Enhertu, Keytruda, Lumizyme, or Opdivo more often than the dose frequency limits per FDA prescribing information.
• Billing for Entyvio or an infliximab product without a diagnosis that aligns with one of the covered diagnoses in the medical policy.
• Exceeding diagnosis-specific maximum allowed units for the date of service for Botox, Dysport, Myobloc, or Xeomin.
• Missing the secondary diagnosis code when required for Keytruda, Opdivo, or a rituximab product.
• Submitting similar or duplicate claims for the same date of service.
• Listing an incorrect route of drug administration for Darzalex Faspro, Phesgo, or a rituximab product.

For related information please see the October 3, 2024, Provider News article on Billing for Wasted and Administered Drugs.