ClaimsXtenTM 2nd Quarter 2016 Updates and New Specialty Pharmacy Rule Notification

April 18, 2016

Blue Cross and Blue Shield of Oklahoma (BCBSOK) reviews new and revised Current Procedural Terminology (CPT®) and Healthcare Common Procedure Coding System (HCPCS) codes on a quarterly basis. Codes are periodically added to or deleted from the ClaimsXten code auditing tool software by the software vendor and are not considered changes to the software version. BCBSOK will normally load this additional data to the BCBSOK claim processing system within 60 to 90 days after receipt from the software vendor and will confirm the effective date via the News and Updates section of the BCBSOK Provider website. Advance notification of updates to the ClaimsXten software version (i.e., change from ClaimsXten version 4.1 to 4.4) also will be posted on the BCBSOK Provider website. 

Beginning on or after July 18, 2016, BCBSOK will enhance the ClaimsXten code auditing tool by adding the second quarter 2016 codes and bundling logic into our claim processing system. BCBSOK will also implement a new Specialty Pharmacy Knowledge Pack rule into our claim processing system. This new rule will apply to professional and outpatient facility claims with dates of service on or after July 18, 2016. The new rule is summarized below: 

The Specialty Pharmacy Knowledge Pack rule will audit professional and outpatient facility claims involving specialty pharmaceuticals utilizing 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.

The ClaimsXten tool offers flexible, rules-based claims management with the capability of creating customized rules, as well as the ability to read historical claims data. ClaimsXten can automate claim review, code auditing and payment administration, which we believe results in improved performance of overall claims management.

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 BCBSOK’s code-auditing software. For more information on C3 and ClaimsXten, including answers to frequently asked questions, refer to the Clear Claim Connection page in the Education and Reference Center/Provider Tools section of our Provider website. Information also may be published in upcoming issues of the Blue Review.