Update: Medical Pharmacy Post Service Claim Edits Denials

This applies to our Commercial line of business only

Update May 15, 2025

Our claim systems vendor has completed the correction to the issue identified below. BCBSND is currently working through the recovery of the denied pharmacy post service claim edits (PSCE) claims with consideration of up to four diagnosis codes as submitted on the original claim. We anticipate this recovery to be completed by the end of June. If you have further questions after the recovery is completed, please contact BCBSND Provider Services by calling the phone number on the back of the member's ID card.

On March 20, 2025, the previous article indicated, Blue Cross Blue Shield of North Dakota (BCBSND) is informing our provider community of a recent known issue with our medical PSCE reviewed by our vendor Medical Pharmacy Solutions team at Prime Therapeutics Management (Prime). We discovered our claims system vendor is allowing only one diagnosis code on the claim for edit review. We should be allowing up to four diagnosis codes for determination of medical necessity. This is causing several PSCE Prime medical claims to reject because of this incomplete data.

We are working with our claim systems vendor for a correction in early May 2025. We are starting to process claims that show a diagnosis code rejection and ask that providers do not send claim corrections or issue an appeal at this time.

BCBSND will issue an update through HealthCare News informing our provider community of the completion of the correction. Once the correction is in place, BCBSND will do recovery of the denied PSCE claims with consideration of up to four diagnosis codes as submitted on the claim.

We do apologize for the inconvenience.