Category Archives: Industry Insights

In Medical Drug Edit Blog Post #1, we saw that pre-payment edits of Medical Drug claims can be utilized to improve claim submission and reimbursement accuracy.  Payors and providers license RJ Health’s Medical Drug Edits and access them via our API platform. This is because effective pre-payment review of medical drug claims requires: •  The […]

In January there was one new drug approval by the FDA we deemed specific to the specialty market. In addition, there were three supplemental drug approvals. The FDA had acted on assignment of new PDUFA dates for three new products for review. Finally, there were two complete response letters issued and one manufacturer triggered withdrawal […]

Drugs covered under medical benefit plans and their costs are difficult to manage. These challenges are due to: •  Limited clinical visibility and control •  Unaccommodating medical claims and claim systems •  Complex billing and reimbursement requirements related to coding and pricing As a result, medically covered drug claim errors are almost the norm.  In […]

Enacted in 1992, the Prescription Drug User Fee Act (PDUFA) was created to authorize the Food and Drug Administration (FDA) to collect fees from companies that produce certain human drug and biological products. These fees serve as a secondary source of funding for the FDA and serve to expedite the review process.  The FDA establishes […]

  Below is the transcript from our On-Demand Micro-Webinar: Where is my NDC? Powered by ReimbursementCodes.com Laura:  Welcome, and good day.  Thanks for joining us.  Today we would like to help you by answering the most frequently asked question about RJ Health Data; Where is my NDC? I’m Laura, Clinical Informatics  Pharmacists with RJ Health, and joining […]

INSIDE THIS ISSUE Code Updates: Large Price Changes New HCPCS® Codes and Changed Code Descriptions are Now Effective Code Strength Description Changes for New HCPCS® Codes CMS News: CMS Final Ruling on Medicare Physician Schedule Now Effective Quarterly ASP (Average Sales Price) Pricing File Released Hospital OPPS (Outpatient Prospective Payment System) Update Drug Reimbursement Code […]

In December there were a total of four new drug approvals by the FDA we deemed specific to the specialty market. In addition, there were six supplemental drug approvals. The FDA had assigned eight new products for review. Drugs included in this review are generally regarded by the industry as specialty drugs.  Qualifiers may include […]

There are several instances where dosing NDC and HCPCS code units don’t agree. Pay special attention when billing for a pediatric dose, that the NDC is billed under the pediatric code if one exists. Each dose has a different NDC unit, and they cross back to the single HCPCS value. If billed under the wrong […]

INSIDE THIS ISSUE Code Updates: Large Price Changes New HCPCS® Codes and Changed Code Descriptions Effective January 1, 2019 CMS News: CMS Final Ruling on Medicare Physician Schedule Effective January 1, 2019 Drug Reimbursement Code Price Updates: 47 Drug Codes required a recalculation of their AWP Code Price Drugs/Devices: New Clinical and Billing Information CODE UPDATES Large […]

New Drug Overview – emapalumab-lzsg (Gamifant®) On November 20, 2018, the U.S. Food and Drug Administration (FDA) approved emapalumab-lzsg (Gamifant®) for the treatment of pediatric (newborn and above) and adult patients with primary hemophagocytic lymphohistiocytosis (HLH) who have refractory, recurrent or progressive disease or intolerance with conventional HLH therapy. Primary HLH is an ultra-rare disease, […]