National Drug Code (NDC) Billing Update for Medicare Advantage Claims
Beginning Dec. 15, 2017, Blue Cross and Blue Shield of Illinois (BCBSIL) will activate edits to validate NDCs that are submitted on electronic and paper, professional and institutional Blue Cross Medicare Advantage (PPO)SM and Blue Cross Medicare Advantage (HMO)SM claims. These validation edits are being implemented to align with the Centers for Medicare & Medicaid Services (CMS) encounter data submission requirements. Providers should confirm that the NDCs submitted on any claims are appropriate for services rendered and active for the date(s) of service billed.
The table below specifies which NDC-related elements must be entered if NDCs are included on electronic professional and institutional claims for Medicare Advantage members. Claims submitted containing NDCs may be rejected if any of these data elements are missing or incorrect. Rejected claims must be resubmitted with the correct data. If you use a billing service or clearinghouse, please share this information with your vendor.
|Elements Required when NDC is Present on Electronic Claims||Professional Electronic Claim (837P) Loops and Segments||Institutional Electronic Claim (837I) Loops and Segments|
|Current Procedural Terminology (CPT®) or Healthcare Common Procedure Coding System (HCPCS) Code||Loop 2400, SV101-1 = HC
Loop 2400, SV101-2 = [CPT/HCPCS code]
|Loop 2400, SV202-1 = HC
Loop 2400, SV202-2 = [CPT/HCPCS code]
|If the CPT/HCPCS code in SV101-2 (professional claim)/SV202-2 (institutional claim) is an unlisted procedure code or Not Otherwise Classified (NOC) code, a description is required||Loop 2400, SV101-7
||Loop 2400, SV202-7|
|Line Item Charge Amount||Loop 2400, SV102||Loop 2400, SV203|
|Unit of Measurement Code||Loop 2400, SV103 = UN||Loop 2400, SV204 = UN|
|Service Unit Count||Loop 2400, SV104||Loop 2400, SV205|
|NDC Qualifier||Loop 2410, LIN02 = N4||Loop 2410, LIN02 = N4|
|NDC (11-character alpha-numeric value containing no spaces, hyphens or special characters)||Loop 2410, LIN03 = NDC Number||Loop 2410, LIN03 = NDC Number|
|Quantity/Dosage* (Number of NDC units)||Loop 2410, CTP04||Loop 2410, CTP04|
|Unit of Measure (UOM = UN, ML, GR or F2)||Loop 2410, CTP05-1||Loop 2410, CTP05-1|
|Prescription Number (when applicable)||Loop 2410, REF01 = XZ
REF02 = [prescription number]
|Loop 2410, REF01 = XZ
REF02 = [prescription number]
If NDCs are submitted on paper professional (CMS-1500) and institutional (UB-04) claims for Medicare Advantage members, the following NDC-related elements must be included:
|Professional Paper Claim (CMS-1500) Fields and NDC-related Information||Institutional (UB-04) Form Locator Numbers and NDC-related Information|
*For assistance with calculating the number of NDC units, independently contracted BCBSIL providers may access the NDC Units Calculator Tool at no cost through our secure site – look for the National Drug Codes (NDCs): Billing Resources link on our Provider website Home page at bcbsil.com/provider. The NDC Units Calculator Tool is also available via the Availity™ Web Portal.
For additional claim-related information, refer to the appropriate Provider Manual in the Standards and Requirements section on our website at bcbsil.com/provider. As always, your assigned BCBSIL Provider Network Consultant is available to provide assistance to you and your staff.
CPT copyright 2016 American Medical Association (AMA). All rights reserved. CPT is a registered trademark of the AMA.
Availity is a trademark of Availity, LLC, a separate company that operates a health information network to provide electronic information exchange services to medical professionals. Availity provides administrative services to BCBSIL. BCBSIL makes no endorsement, representations or warranties regarding any products or services provided by third party vendors such as Availity. If you have any questions about the products or services provided by such vendors, you should contact the vendor(s) directly.