Reconsideration of Unlisted Code Allowances

Billing and Reimbursement
Policy Number: RP-X-004

Last Updated: March 6, 2024

Unlisted drug codes, such as J3490, should only be submitted if there is no other code that describes the drug. All unlisted drugs must be submitted with a narrative, dosage and NDC. 

There may be times when the invoice cost of the drug is significantly higher than BCBSNE’s allowance. In such cases, the provider may submit a reconsideration for additional reimbursement using the reconsideration process described in the Reconsideration Requests Policy GP-X-073.

To facilitate this review, the drug invoice must be submitted with the reconsideration form. Additional reimbursement will not be considered without the invoice. BCBSNE reserves the right to determine a cost threshold for any requested reconsiderations that is cost-efficient for providers and members. The threshold for a reconsideration review is $25 allowed difference based on current costs of claims handling.