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Remicade® (infliximab) Claims Review Process

Horizon Blue Cross Blue Shield of New Jersey continues to collaborate with Magellan Rx Management, a specialty pharmaceutical management company, to conduct medical necessity and appropriateness reviews (MNARs) for specific injectable medications through our Medical Injectables Program (MIP).

A recent review of processed claims for injectable medications within the MIP revealed that some claims for Remicade® (infliximab) were submitted with a frequency or dosage in excess of the amount originally approved by Magellan Rx Management (MRxM). This may be due to errors that are made in billing the proper number of units administered to a patient or to changes made in dosage or frequency due to a patient’s changed medical circumstances. MNAR determination letters sent by MRxM contain the dosage and frequency approved during the pre-service clinical review process.

Beginning July 17, 2017, MRxM will enhance its claim review process to help ensure that Remicade claims for services rendered on and after July 17, 2017 do not exceed the specific dosage and frequency authorized by MRxM.

As a result:

  • Remicade claim lines consistent with the information approved within the MRxM authorization will be processed and reimbursed without delay.
  • Remicade claim lines that contain inconsistent or excessive dosage or frequency information when compared to the approved MRxM authorization will result in the inconsistent or excessive dosage or frequency portion of the claim being denied. In that event, appeal rights will be provided with the claim determination.

As a result, physicians, other health care professionals, hospitals and ancillary providers are reminded that MRxM must be contacted if changes to an approved MNAR’s frequency/dosage is required as a result of a patient’s changed medical circumstances.

If you have any questions, please contact your Network Specialist, Network Hospital Specialist or Ancillary Contracting Specialist.

Remicade® is a registered trademark Janssen Biotech, Inc.

Published on: June 15, 2017, 09:17 a.m. ET
Last updated on: June 15, 2017, 14:33 p.m. ET