CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Coding and Claim Filing Requirements for Drugs

Defines BCBSRI's requirements for submitting medical drug claims (professional and facility) for Commercial and Medicare Advantage plans, specifying required HCPCS/CPT and NDC reporting and pricing rules.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyCoding and Claim Filing Requirements for Drugs

Policy CodePolicy N/A

Change TypeClaim filing requirement added

Effective DateJul 1, 2022

Next Review DateN/A

Key ActionSubmit both a valid HCPCS/CPT code and an 11-digit NDC on all drug claims; if no valid HCPCS/CPT exists use an unlisted HCPCS/CPT with the 11-digit NDC.

SourceLink

POLICY UPDATE CHANGES

Effective for dates of service on or after July 1, 2022, BCBSRI requires drugs for all claims to be filed with both a valid HCPCS/CPT code and appropriate National Drug code (NDC).

2claim elements required (HCPCS/CPT + 11-digit NDC)

11-digitrequired NDC format

2022-07-01effective date for filing requirement

HCPCS/CPT or NDCpricing basis

Drug Claim Submission and Processing Criteria

Drug claim filing criteria

Submission and processing criteria for drug claims:

Claims must include BOTH a valid HCPCS/CPT code and a valid 11-digit NDC that matches the medication administered and matches the HCPCS/CPT billed.

Claims without required elements

Claims filed with a valid drug HCPCS/CPT code only (no NDC) will not be accepted for processing.
Claims filed with a valid NDC without a HCPCS/CPT code will not be accepted for processing.

Claims filed with both a valid HCPCS/CPT code AND a valid 11-digit NDC will be accepted for processing.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyCoding and Claim Filing Requirements for Drugs

Policy CodePolicy N/A

Change TypeClaim filing requirement added

Effective DateJul 1, 2022

Next Review DateN/A

Key ActionSubmit both a valid HCPCS/CPT code and an 11-digit NDC on all drug claims; if no valid HCPCS/CPT exists use an unlisted HCPCS/CPT with the 11-digit NDC.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Required Coding and NDC Format

Covered codesmixedCovered

J9217	Leuprolide Acetate, Per 7.5 MG
unlisted HCPCS/CPT	Use only when no valid HCPCS/CPT exists; must be submitted with 11-digit NDC

NDC format required — 11-digit

Required NDC format11-digit NDC is required on all drug claims (must be valid and current)

When to useAlways submit an 11-digit NDC with a valid HCPCS/CPT code; unlisted HCPCS/CPT must also be submitted with the 11-digit NDC

Matching requirementNDC must match the medication administered and must match the HCPCS/CPT billed

Processing consequenceClaims filed without the 11-digit NDC (or with incorrect NDC format) will not be accepted for processing

Provider Billing Requirements and Audit Risk

Billing Rule

Claim submission requirement: HCPCS/CPT + 11‑digit NDC

Effective for dates of service on or after July 1, 2022, submit both a valid HCPCS/CPT code and an 11‑digit NDC on all drug claims. If there is no valid HCPCS/CPT code for the drug administered, use an unlisted (not otherwise classified) HCPCS/CPT code submitted with the 11‑digit NDC; unlisted codes should only be used when no valid HCPCS/CPT exists. NDC must match the medication administered and must match the HCPCS/CPT billed. Pricing is determined by the HCPCS/CPT and its unit of measure unless an unlisted HCPCS/CPT is used, in which case pricing and the unit of measure will be determined by the NDC.

Required on all drug claims: a valid HCPCS/CPT code and a valid 11‑digit NDC.
If no valid HCPCS/CPT exists: submit an unlisted HCPCS/CPT with the 11‑digit NDC (use unlisted only when no valid HCPCS/CPT exists).
NDC must match the medication administered and the HCPCS/CPT billed.
Pricing basis: HCPCS/CPT (unit of measure = HCPCS/CPT); if unlisted HCPCS/CPT used, pricing and unit of measure = NDC.

Denial Risk

Claims subject to audit and potential recovery

All claims filed are subject to audit and potential recovery of payment if the HCPCS/CPT code, NDC, their combination, or the unit of measure are used inappropriately or incorrectly.

BCBSRI may audit submitted claims and recover payments when inappropriate coding, incorrect NDC use, or incorrect unit of measure is identified.

Key Terms and Pricing Basis

NDC — National Drug Code

DefinitionNational Drug Code (NDC) numbers are an industry standard identifying number for drugs and provide information pertaining to the medication administered.

PurposeUsed to identify the exact drug administered for claim submission and pricing

Required representationBCBSRI requires a valid 11-digit NDC on all drug claims submitted with HCPCS/CPT or unlisted codes

Unlisted HCPCS/CPT with NDC — pricing and submission

Pricing ruleWhen an unlisted (not otherwise classified) HCPCS/CPT is used with an NDC, pricing will be determined by the NDC and the unit of measure shall be the NDC

When allowedUnlisted HCPCS/CPT codes must ONLY be used when no valid HCPCS/CPT exists for the drug administered

Submission requirementAll unlisted HCPCS/CPT codes must be submitted with the 11-digit NDC number

Processing outcomeDrug claims filed with an unlisted HCPCS/CPT and an NDC will be accepted for processing and priced using the NDC