September 2017

Medicaid Claim Denials for No Drug Rebate Agreement on File

As a reminder, National Drug Codes (NDCs) and all other required data elements must be billed on medical claims for Illinois Medicaid members. Additionally, a signed Medicaid Drug Rebate Agreement from each drug’s manufacturer, or pharmaceutical labeler, must be on file with the Centers for Medicare & Medicaid Services (CMS). This means that, even if the NDC is valid for the date of service and all other required elements are included, claims will be denied if there is no rebate agreement on file with CMS for a particular manufacturer.

For more information, refer to the Medical Providers section of the Illinois Healthcare and Family Services (HFS) website at illinois.gov/hfs, where you will find the following resources:

• List of Healthcare Common Procedure Coding System (HCPCS) codes requiring NDCs
• List of Pharmaceutical Labelers with Signed Rebate Agreements

Also refer to the Claims Handling for Medicaid Members and other Related Resources on the Medicare/Medicaid page in the Network Participation section of BCBSIL’s Provider website.