Postpayment Service-Specific Probe Results for Denosumab (Prolia) for January through March 2021

Palmetto GBA performed service-specific postpayment probe review on HCPCS Code J0897 — Denosumab (Prolia). This edit was set in Alabama, Georgia and Tennessee. The results for the first quarter postpayment review, for claims processed January through March, 2021, are presented here.

Cumulative Results 
A total of 42 claims were reviewed, with none of the claims completely or partially denied, resulting in an overall claim denial rate of 0.0 percent. The total dollars reviewed was $19,574.41, of which $0.00 was denied, resulting in a charge denial rate of 0.0 percent. Overall, there were no auto-denied claims in the region. 

Alabama Results
A total of 15 claims were reviewed, with none of the claims either completely or partially denied. This resulted in a claim denial rate of 0.0 percent. The total dollars reviewed was $9,481.93, of which $0.00 was denied, resulting in a charge denial rate of 0.0 percent. 

Georgia Results
A total of 27 claims were reviewed, with none of the claims either completely or partially denied. This resulted in a claim denial rate of 0.0 percent. The total dollars reviewed was $10,092.48, of which $0.00 was denied, resulting in a charge denial rate of 0.0 percent. 

Tennessee Results
There were no claims reviewed in Tennessee during this processing period.

The Next Steps
The service-specific post payment medical review edits for HCPCS Code J0897 — Denosumab (Prolia) in Alabama, Georgia, and Tennessee will be continued based on moderate charge denial rates and/or medium to high impact severity errors. If significant billing aberrancies are identified, provider-specific review may be initiated.

If you are dissatisfied with a claim determination you have the right to request an appeal. Palmetto GBA encourages you to review the documentation originally submitted, and if you believe you have additional supporting documentation you may include this information with your appeal. For more information related to the appeals process please refer to Redetermination: 1st Level Appeal Form (PDF, 236 KB). Questions regarding this medical review can be directed to the Palmetto GBA Provider Contact Center at 877–567–7271.