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Aetna Reviews Medical Drug Claims
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Aetna validates the number of units administered and the submitted charges of medications with a dosing algorithm. This algorithm applies to claims for medications billed with Healthcare Common Procedure Coding System (HCPCS) codes, as well as medical drug claims billed with a National Drug Code (NDC).
The algorithm reviews claims to identify possible overbilling errors that exceed standard dosing thresholds. It denies the portion of these claims that exceeds maximum dosing levels based on the product labeling, Food and Drug Administration (FDA) dosing guidelines and peer-reviewed, published medical literature for each drug.
For a list of applicable medications, visit Aetna’s secure provider website. Once logged in, select “Aetna Support Center”, then “Claims” and “CPT/HCPCS Coding Tools.”
