New Policy Updates - Clinical Payment, Coding, and Policy Changes Effective October 1, 2025

By September 30, 2025: Billing team must implement the following updates in billing system and provider communications: (1) For obstetric claims: Configure system to require both multiple gestation diagnosis code AND complication-specific diagnosis code on the same claim; flag claims missing either code for denial prevention. (2) For DME claims: Update validation rules to verify referring and ordering NPIs are eligible specialists enrolled in Medicare in approved status; reject claims that fail this check before submission. (3) For drug claims: Configure system to validate NDC codes against HCPCS codes submitted; reject claims where NDC does not match non-specific HCPCS code in NDC Crosswalk; add edit to alert billing staff of mismatches. (4) For vaccine claims: Implement duplicate claim logic that compares subscriber/member number, dependent number, date of service, procedure code, and units across all claims and claim types; automatically deny second submission for same vaccine on same date of service by any provider. (5) For Infliximab claims (J1745, Q5103, Q5104, Q5109, Q5121): Create frequency limit logic for patients age ≥18 with regional enteritis diagnosis—block claims exceeding 5 administrations per 26-week rolling period from any provider on any claim type. Update all encounter forms, billing workflows, and provider alerts. Communicate these changes to all providers, particularly obstetrics, gastroenterology, DME suppliers, and immunology practices. Failure to implement will result in claim denials and potential overpayments.