Get Chenodal (chenodiol) Covered by Blue Cross Blue Shield in Pennsylvania: ICD-10, NDC, and Billing Guide
Answer Box: Getting Chenodal Covered in Pennsylvania
Chenodal (chenodiol) requires prior authorization from all Blue Cross Blue Shield plans in Pennsylvania, including Highmark and Independence Blue Cross. Step 1: Ensure proper ICD-10 coding (K80.20 for radiolucent gallstones). Step 2: Submit PA with imaging proof of radiolucent stones, surgical ineligibility documentation, and failed ursodiol trial records. Step 3: If denied, use Pennsylvania's new External Review Program—50% of appeals are overturned. Submit electronically via Availity for Highmark or fax to 1-888-671-5285 for Independence Blue Cross.
Table of Contents
- Coding Basics: Medical vs. Pharmacy Benefit
- ICD-10 Mapping for Chenodal Coverage
- Product Coding: NDC, Units, and Dosing Math
- Clean Prior Authorization Anatomy
- Frequent Billing Pitfalls
- Verification with Pennsylvania Blue Plans
- Quick Pre-Submission Audit
- Appeals Playbook for Pennsylvania
- Common Denial Reasons & Fixes
- FAQ
Coding Basics: Medical vs. Pharmacy Benefit
Chenodal (chenodiol) is processed through the pharmacy benefit for all Pennsylvania Blue Cross Blue Shield plans, not the medical benefit. This means:
- No J-codes apply—Chenodal doesn't have a HCPCS J-code assignment
- Claims use NDC numbers and pharmacy prior authorization forms
- Billing goes through pharmacy benefit managers like Prime Therapeutics
- Providers submit PA requests electronically (Highmark) or via fax (Independence Blue Cross)
Understanding this distinction prevents the most common initial billing error: attempting to bill Chenodal through medical claims with invented procedure codes.
ICD-10 Mapping for Chenodal Coverage
Primary ICD-10 Codes for Chenodal:
- K80.20: Calculus of gallbladder without cholecystitis, without obstruction
- K80.80: Other cholelithiasis, without obstruction
Documentation Requirements: Your medical records must clearly state that gallstones are radiolucent (non-calcified). Blue Cross Blue Shield policies specifically require imaging confirmation showing radiolucent cholesterol stones. Documentation should include:
- Ultrasound or CT scan reports noting "radiolucent" or "non-calcified" stones
- Stone size and number
- Gallbladder function assessment
- Absence of acute cholecystitis or obstruction
Tip: The phrase "radiolucent gallstones confirmed by imaging" should appear in your clinical notes. This exact language helps PA reviewers quickly identify medical necessity.
Product Coding: NDC, Units, and Dosing Math
Chenodal NDC and Billing Details:
| Component | Details |
|---|---|
| Primary NDC | 67386-0301-01 (250 mg tablets) |
| Manufacturer | Travere Therapeutics |
| Dosing Formula | 16 mg/kg/day (FDA maximum) |
| Tablet Strength | 250 mg only |
| Billing Units | Per tablet dispensed |
Dosing Calculation Example:
- Patient weight: 70 kg
- Maximum daily dose: 70 kg × 16 mg/kg = 1,120 mg/day
- Tablets needed: 1,120 mg ÷ 250 mg = 4.48 tablets
- Round down to 4 tablets daily (1,000 mg/day)
- 30-day supply = 120 tablets
Critical: Never exceed 16 mg/kg/day or round up tablet counts. Blue Cross Blue Shield automatically denies claims exceeding FDA dosing guidelines.
Clean Prior Authorization Anatomy
Pennsylvania Blue Cross Blue Shield PA Requirements:
Highmark Blue Cross Blue Shield
- Submission: Electronic only via Availity portal (fax no longer accepted as of 2024)
- Timeline: 72 hours standard, 24 hours urgent
- Required Elements:
- Patient demographics and insurance ID
- Prescriber NPI and credentials
- NDC: 67386-0301-01
- Weight-based dosing calculation
- ICD-10: K80.20 or K80.80
- Clinical documentation package
Independence Blue Cross
- Submission: Fax to 1-888-671-5285
- Timeline: 2 business days
- Follow-up: Call 1-888-678-7012 if no response
- Same clinical requirements as Highmark
Clinical Documentation Package Must Include:
- Imaging report confirming radiolucent gallstones
- Surgical consultation noting patient is not a candidate for cholecystectomy
- Documentation of ursodiol trial failure or intolerance (minimum 6 months)
- Recent liver function tests (ALT, AST, bilirubin, alkaline phosphatase)
- Gastroenterologist or hepatologist consultation preferred
Frequent Billing Pitfalls
Top 5 Coding Errors That Cause Denials:
- Incorrect NDC submission - Using generic ursodiol NDCs instead of Chenodal's specific 67386-0301-01
- Dosing miscalculations - Exceeding 16 mg/kg/day or incorrect unit conversions
- Missing weight documentation - PA forms require actual body weight for dose verification
- Wrong ICD-10 codes - Using K80.21 (with obstruction) when patient has K80.20 (without obstruction)
- Days supply errors - Mismatch between tablets dispensed and calculated daily dose
From Our Advocates: "We've seen claims approved within 48 hours when providers include the exact phrase 'radiolucent cholesterol gallstones confirmed by ultrasound' in their PA submission. Small documentation details make a significant difference in Pennsylvania Blue Cross reviews."
Verification with Pennsylvania Blue Plans
Pre-Submission Checklist:
Highmark Verification
- Log into Availity provider portal
- Check current formulary status for Chenodal
- Verify PA form requirements haven't changed
- Confirm electronic submission pathway is working
Independence Blue Cross Verification
- Visit IBX provider website pharmacy section
- Download most recent PA form
- Test fax line 1-888-671-5285 for connectivity
- Confirm backup phone number 1-888-678-7012
Cross-Check Your Coding:
- Patient weight × 16 mg/kg = maximum daily dose
- Daily dose ÷ 250 mg = tablets per day (round down)
- Verify NDC 67386-0301-01 matches your pharmacy system
- Confirm ICD-10 code matches imaging findings
Quick Pre-Submission Audit
Before submitting your Chenodal PA:
✅ Patient eligibility verified with current Pennsylvania Blue Cross ID
✅ Weight-based dosing calculated and not exceeding 16 mg/kg/day
✅ NDC 67386-0301-01 confirmed in pharmacy system
✅ ICD-10 K80.20 or K80.80 matches clinical documentation
✅ Radiolucent stones confirmed by imaging report
✅ Surgical ineligibility documented by specialist
✅ Ursodiol failure records attached (minimum 6 months)
✅ Recent liver function tests included
✅ Correct submission method used (Availity for Highmark, fax for IBX)
Appeals Playbook for Pennsylvania
Pennsylvania launched its Independent External Review Program in January 2024, giving patients a powerful new tool. Success rate: 50% of appeals are overturned.
Internal Appeal (Required First Step)
- Timeline: Submit within 60 days of denial
- Method: Same portal/fax used for original PA
- Include: Specific response to denial reason plus any missing documentation
External Review (Pennsylvania's New Program)
- Eligibility: Must have Final Adverse Benefit Determination letter
- Timeline: 4 months to request after internal appeal
- Submission: Online at pa.gov or mail to Pennsylvania Insurance Department
- Decision: 45 days standard, 72 hours expedited
- Binding: Insurers must comply immediately if overturned
Pennsylvania Insurance Department Contact:
- Phone: Available on pa.gov consumer services
- Website: pa.gov (search "external review")
- Consumer Assistance: Pennsylvania Health Law Project provides free help
Common Denial Reasons & Fixes
| Denial Reason | Fix Strategy |
|---|---|
| "Not medically necessary" | Add specialist letter explaining why surgery isn't appropriate; include comorbidity documentation |
| "Step therapy not met" | Submit detailed ursodiol trial records showing 6+ months of treatment and failure/intolerance |
| "Incorrect dosing" | Recalculate using patient's actual weight; ensure not exceeding 16 mg/kg/day |
| "Missing imaging" | Attach radiology report explicitly stating "radiolucent" or "non-calcified" gallstones |
| "Non-formulary" | Request formulary exception with comparative effectiveness data vs. ursodiol |
Coverage at a Glance
| Requirement | Details | Source |
|---|---|---|
| PA Required | Yes, all PA Blue Cross plans | BCBS Policy Documents |
| Step Therapy | Ursodiol failure required | PA Criteria |
| Dosing Limit | 16 mg/kg/day maximum | FDA Label |
| Duration | Up to 18 months | Coverage Policies |
| Monitoring | Liver function tests required | Clinical Guidelines |
FAQ
How long does Blue Cross Blue Shield PA take in Pennsylvania?
Highmark: 72 hours standard, 24 hours urgent via Availity. Independence Blue Cross: 2 business days via fax.
What if Chenodal is non-formulary on my plan?
Request a formulary exception by documenting ursodiol failure and providing clinical rationale for Chenodal's unique mechanism.
Can I request an expedited appeal?
Yes, if there's an urgent medical need. Pennsylvania's external review offers 72-hour expedited decisions for urgent cases.
Does step therapy apply if I failed ursodiol in another state?
Yes, but you must provide complete documentation of the previous trial, including duration, dosing, and reason for discontinuation.
What happens if my external review is approved?
The insurer must immediately provide coverage, including retroactive payment if you paid out-of-pocket during the appeal.
About Counterforce Health
Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into successful appeals. Our platform analyzes denial letters and plan policies to create targeted, evidence-backed appeals that align with each payer's specific requirements. We've helped thousands of patients access specialty medications like Chenodal by identifying the exact denial basis and crafting point-by-point rebuttals with the right clinical evidence and procedural requirements.
Sources & Further Reading
- Chenodal Coverage Guide - Counterforce Health
- Pennsylvania External Review Program - PA.gov
- Highmark Provider Resources
- Independence Blue Cross PA Forms
- FDA Chenodiol Labeling Information
Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage policies vary by plan and change frequently. Always consult your specific Blue Cross Blue Shield plan documents and speak with your healthcare provider about treatment decisions. For personalized help with appeals, contact the Pennsylvania Insurance Department or consider working with a patient advocacy organization like Counterforce Health.
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