In August 2024, the California Medical Association (CMA) was notified by a physician practice that Blue Shield of California was mistakenly denying claims for the physician administered medication Udenyca (Q5111), citing a lack of prior authorization. This occurred despite the practice verifying with Blue Shield that prior authorization was not required. 

After CMA raised the issue with Blue Shield, the insurer identified a system issue in its prior authorization and post-service review tool that caused claims for Udenyca submitted across its physician network to be denied in error. Blue Shield identified approximately 700 claims, dating back to January 1, 2024, that had been wrongly denied  

Blue Shield implemented a system fix on August 1, 2024, and launched a claim reprocessing project that was completed by September 11, 2024, paying impacted providers an estimated $1.1 million dollars in payments due. 

Physicians are advised to review their records to ensure all affected claims have been reprocessed accurately. If any discrepancies are found, practices should contact Blue Shield.