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New Claims Editing Rules To Be Implemented in December 2026
BCBS Montana·MT · Ophthalmology, Endocrinology, Rheumatology +1 more·Reimbursement
Effective date
Dec 1, 2026
We identified it
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.
Action Required
By November 30, 2026: Billing team must implement the following in the billing system and communicate to all providers: (1) Configure 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. (2) Ensure all single-use vial/package drug codes require JW or JZ wastage/discard modifiers or claims will be edited. (3) Update provider communication materials and EMR templates to reflect new coding requirements. (4) Use Clear Claim Connection tool to test billing combinations before December 1. (5) Staff 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. Failure to comply will result in claim denials and payment delays for affected drugs.