Prime Therapeutics Post Service Claim Edits Program

Effective Date: July 1, 2026

In collaboration with Prime Therapeutics, a Post Service Claim Edit (PSCE) program will be implemented for select physician‑administered drugs billed under the medical benefit.

What You Need to Know

The PSCE program applies automated claim edits after claim submission to support consistent claim evaluation based on established clinical criteria. Depending on the medication, claims may be evaluated for:

• Eligible diagnosis
• Dosage or units billed
• Frequency or duration of therapy
• Loading doses
• Applicable drug waste (JW modifier)

What Providers Need to Do

No changes to current claim submission processes are required. Providers should continue submitting claims in accordance with existing BCBSKS requirements.

If a claim does not meet applicable criteria, the Explanation of Benefits (EOB) will identify the reason for the adjustment or denial.

Additional Resources

Applicable medical policies are available on www.GatewayPA.com in a section at the top dedicated to PSCE.

For questions or additional support, please contact the Prime Therapeutics Medical Pharmacy Solutions Provider Relations team at [email protected].