← Back to list
New Claims Editing Rules To Be Implemented in December 2026
Act
by Nov 30, 2026
Effective date
Dec 1, 2026
Identified
Aug 22, 2026
Summary
Blue Cross Blue Shield of Montana is implementing new claims editing rules effective December 1, 2026, that will enforce specific dosage and frequency limits for five injectable drugs (Denosumab, Aflibercept, Ranibizumab, Pasireotide, and Ranibizumab-eqrn) and require proper application of drug wastage modifiers. Claims exceeding these limits will be edited with reason codes beginning with 'G' and will be subject to denial or adjustment.
Get alerts when payers change rules like this one
We check BCBS Montana and other payers every day and email you when a change matches your specialty and state.
Get BCBS Montana alertsPolicy Monitoring is free. No card required.
What to do
by Nov 30, 2026 · 6 steps
01Billing team must implement the following in the billing system and communicate to all providers.
02Configure system edits to enforce maximum dosage limits—J0897: 60 units per 6 months for osteoporosis diagnoses; J0178: 4 units per 4 weeks; J2778: 5 units per 4 weeks; J2502: 60 units per 4 weeks for acromegaly diagnoses; Q5128: 10 units per 4 weeks for wet AMD, RVO, or mCNV diagnoses.
03Ensure all single-use vial/package drug codes require JW or JZ wastage/discard modifiers or claims will be edited.
04Update provider communication materials and EMR templates to reflect new coding requirements.
05Use Clear Claim Connection tool to test billing combinations before December 1.
06Staff should expect edited claims with 'G' prefix reason codes starting December 1 and be prepared to review for medical necessity or resubmit with corrected dosages.
If missed: Failure to comply will result in claim denials and payment delays for affected drugs.
Codes mentioned
J0897J0178J2778J2502Q5128
Original notice
New Claims Editing Rules To Be Implemented in December 2026
bcbsmt.com · Always check the source before changing claims.