Wisconsin – Anthem BCBSWI Medicaid Updates Unlisted, Unspecified or Miscellaneous Codes

May 2018 ~

Anthem Blue Cross and Blue Shield of Wisconsin (BCBSWI) has published coding and prior authorization updates scheduled to take effect over the coming months. These updates are as follows.

Eight Injectable Drugs will Require Prior Authorization Update

Effective June 1st, BCBSWI will require prior authorization (PA) for eight injectable drugs.

BCBSWI is adding PA requirements to the following codes:

  • J0565 — Injection, bezlotoxumab, 10 mg
  • J1428 — Injection, eteplirsen, 10 mg
  • J2326 — Injection, nusinersen, 0.1 mg
  • J2350 — Injection, ocrelizumab, 1 mg
  • J9022 — Injection, atezolizumab, 10 mg
  • J9023 — Injection, avelumab, 10 mg
  • J9285 — Injection, olaratumab, 10 mg
  • Q2040 — Tisagenlecleucel

Federal and state law, as well as state contract language including definitions and specific contract provisions/exclusions, take precedence over these prior authorization rules and must be considered first when determining coverage. Noncompliance with these new requirements may result in denied claims. For detailed authorization requirements, providers should refer to the Precertification Lookup Tool.

Unlisted, Unspecified or Miscellaneous Codes (Policy 06-004)

As of July 1st, BCBSWI will require unspecified diagnosis codes to only be used when an established diagnosis code does not exist to describe the diagnosis. Reimbursement will be based on review of the unspecified diagnosis code on an individual claim basis. If the claim must have an unspecified diagnosis code, and there is a corresponding left, right or bilateral diagnosis, then a description supporting the use of the unspecified diagnosis code must be provided.



Source(s): Anthem BCBS Blue Cross Blue Shield Network Update – April 2018;