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NDC code submission changes effective January 1, 2009

We want to remind you of some changes to National Drug Code (NDC) submission that went into effect January 1, 2009, as part of our overall approach to managing specialty pharmaceutical benefits.

Please be advised that an edit is now in place to validate the NDC on any paper or electronic claims submitted with an unlisted and/or non-specific drug code. Please review the billing requirements listed below for your applicable provider type. By requesting this detailed drug billing information, we can provide greater transparency for our members and providers. Certain claims for unlisted and non-specific drug codes that are not accompanied by an NDC in the correct format and location will not be processed and will be returned to you for correction and resubmission. Please note that this requirement applies to all claims received after January 1, 2009 and is not based on date of service.

For professional providers: Effective January 1, 2009, claims for all unlisted and non-specific drug codes (CPT® or HCPCS) require submission of an NDC in the correct format and location. If the NDC is not submitted in the correct format or is missing, the claim will not be processed and will be returned to you for correction. The complete list of unlisted and non-specific codes that require the submission of an NDC can be found in the January 2009 partners in Health Update.

For home infusion providers: Effective January 1, 2009, all drug claims (not just the unlisted and nonspecific CPT or HCPCS codes listed in the January 2009 Partners in Health Update) require the submission of an accompanying 11-digit NDC. This includes claims for hemophilia factor products that are currently submitted with specific J codes.

For institutional providers: Scheduled for future release in 2009, all claims for outpatient services containing the following pharmacy revenue codes and an unlisted and/or non-specific (CPT or HCPCS) code will require a valid NDC when submitted: 250-259, 262, 263, 331, 332, 335, 343, 344, and 631-637.

NDC billing information Please submit the NDC using the 5-4-2 format when billing with hyphens (e.g., 12345-1234-12). NDC numbers without hyphens (e.g., 12345678911) will also be accepted. Please do not include spaces, decimals, or other characters in the 11-digit string or the claim will be returned for correction prior to processing.

Unlisted codes that will require submission of an NDC*

*These codes are subject to change pending routine updates.

Listing these codes on the table does not imply that a separate payment will be made for the code; that all current and future coding edits apply, and that these codes should only be reported when there is not a more specific code.

For information on claims submission resolution, please refer to the Claims Preprocessing Edits Claims Resolution Document (12/2008). If you have questions, please contact your Network Coordinator or Hospital/Ancillary Services Coordinator.