Promoting and protecting the health and safety of all Idahoans
Español    Idaho.gov    About Us    Contact Us  

View Article

TO:                         All Professional Providers Billing Medications with HCPCS codes

 

FROM:                  Kathleen P. Allyn, Deputy Administrator

 

         

This Information Release is a follow-up to IR MA03-69, “Requirement of National Drug Code (NDC)”, published on pages 11 and 12 in the October 2003 MedicAide provider newsletter. This IR may be accessed online at:

http://www2.state.id.us/dhw/medicaid/MedicAide/1003.pdf .

 

Professional claims for medications reported with HCPCS (Healthcare Common Procedure Coding System) codes for dates of service on or after February 1, 2004 must include the NDC of the medication supplied, units dispensed, and basis of measurement for each HCPCS medication.

 

This requirement:                

·         also applies to cancer drugs with HCPCS codes

·         applies to claims submitted electronically and on the paper CMS 1500 form

·         does not apply to Medicare claims which “crossover” to Medicaid as the secondary payer

 

The HCPCS medications that will require NDC information are listed in the current HCPCS Level II Expert manual, Appendix 3, alphabetically by both generic and brand or trade name with corresponding HCPCS codes.

 

Claims with incomplete NDC information will be denied with EOB 628 – “NDC required….”.

 

The collection of the NDC information will allow Medicaid to collect rebates due from drug manufacturers, resulting in significant cost saving to Idaho’s Medicaid Program. This requirement is supported by the federal Centers for Medicare and Medicaid Services (CMS), which is encouraging all states to develop systems to claim drug rebates for the Medicaid programs. See State Medicaid Director Letter #03-002, at: http://www.cms.hhs.gov/states/letters/smd031403.pdf.

 

 

Electronic Claims

 

PES SOFTWARE:

 

Electronic billing is the quickest and most accurate way to submit Medicaid claims. The HIPAA compliant fields needed to report NDC information are already available for providers using the EDS billing software PES (Provider Electronic Solutions). Providers who are not set up to bill electronically with PES software may contact an EDS Provider Services Representative for more information toll-free at 1-800-685-3757, or 383-4310 in the Boise area.

 

Complete the Service and RX tab fields using the following guidelines.

 

SERVICE Tabs:

  • Complete Service Tabs 1 and 2 as appropriate.
  • Bring up Service Tab 3, complete appropriate fields, and mark Y in the RX Ind field, which will brings up the RX tab which must then be opened and completed:

 

RX Tab:

·         NDC - Enter the 11 digit NDC number.

·         Prescription Number – not required.

·         Units – Enter the units dispensed that you are billing for. You may want to refer to the HCPCS manual, Appendix 3, which includes brief directions regarding the “Amount” (Unit) column.

·         Basis of Measurement – Enter IU – International Units, GR – grams, ML – milliliters, or UN – units (such as the number of tablets, capsules).

·         Unit Price – Enter the price for the HCPCS medication dispensed.

 

If you have questions, refer to the Idaho Provider Electronic Solutions Handbook, Section 9 (837 Professional Forms) which can be accessed online at:

http://www2.state.id.us/dhw/medicaid/provhb/ipesh_handbook.pdf

 

Providers using vendor software:

 

Check with your vendor or clearinghouse. If your software does not allow NDC information to be submitted in the appropriate HIPAA approved fields, you may use the Comment field for NDC information for no longer than 6 months while your software is being modified. Be sure to refer to the detail number in your Comments.

 

After August 1, 2004 claims submitted without NDC information in HIPAA approved fields will be automatically denied.

 

what if Your vendor software is not ready on feb. 1,  2004?

 

You do not have to delay submitting outpatient Medicaid claims if one or more details include HCPCS medications. Here are your options for getting your claims processed as quickly as possible:

  • You can bill the rest of the claim electronically, and wait to bill the line item details which need NDC information until your software is ready. You have up to one year from the date of service to bill any part of a claim, or
  • You can bill the details which need NDC information on a paper CMS 1500 claim form, separate from the rest of your electronic claim.

 

 

 

Paper Claims

 

BILL PAPER CLAIMS ON THE CMS 1500 form

 

For each HCPCS medication detail, use the following guidelines:

  • Submission of the NDC Detail Attachment is required with paper claim forms when submitting a medication billed with a HCPCS code. For each HCPCS medication, complete the attachment with corresponding detail number, NDC number, description, units dispensed, basis of measurement, and total charges.
  • The NDC Detail Attachment is available electronically to be printed out and copied for your use. It can be found on page 12 at: http://www2.state.id.us/dhw/medicaid/MedicAide/1003.pdf
  • Providers can avoid filling out the NDC Detail Attachment by submitting their claims electronically.

 

Please refer to the Idaho Provider Handbook, Section 3, for additional billing information. This handbook can be accessed online at: http://www2.state.id.us/dhw/medicaid/provhb/s3_physician_osteo.pdf

 

Any questions about this Information Release should be directed to EDS at 1-800-685-3757 or 383-4310 in the Boise area.

Thank you for your continued participation in Idaho’s Medicaid Program. 

 

KPA/af