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:
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.
· 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 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.
· 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:
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:
BILL PAPER CLAIMS ON THE CMS 1500 form
For each HCPCS medication detail, use the following guidelines:
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.