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Immunosuppressive Drugs Pre-Pay Review Quarterly Status Report

Below is the analysis of claim denials for immunosuppressive drugs HCPCS codes J7503, J7507, J7518, J7520, and J7527 reviewed July 1 – September 30, 2024. The error rate for this quarter is 6.87 %. The top 4 reasons for claim denials are as follows:

Rank Reason Percent
1. The documentation does not have a valid standard written order. 262.50%
2. The documentation is incomplete. 12.50%
3. The supplier billed for greater quantity than the order shows. 12.50%
4. Documentation does not include information that supports that the beneficiary had a Medicare approved transplant. 12.50%

*The total percentage will be greater than 100% because some claims denied for multiple reasons.

**The error rate included is an overall average for the supplier specific reviews as a part of the Targeted Probe and Educate program. This is not meant to be an overall error rate for the HCPCS code or policy under medical record review.

Resources:

Updated: November 5, 2024

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