CurrentEmblemHealthPolicy RPC2O230040

Drugs and Biologicals Payment Policy (Commercial, Medicare and Medicaid)

Governs reimbursement and billing rules for drugs and biologicals (bundled vs separately payable) across EmblemHealth and ConnectiCare commercial, Medicare, and Medicaid products; applies to hospital outpatient and facility claims and providers billing under these plans.

Policy Summary

PayerEmblemHealth

PolicyDrugs and Biologicals Payment Policy (Commercial, Medicare and Medicaid)

Policy CodePolicy RPC2O230040

Change TypeClarification — billing under revenue code 0636

Effective DateMar 1, 2024

Next Review Date

Key ActionProviders must report total quantity administered, the NDC, and the administration date on the claim and use the correct HCPCS codes for items billed.

SourceLink

POLICY UPDATE CHANGES

Hospital claims for drugs and biologicals must be billed with the appropriate HCPCS codes when billed under revenue code 0636 (whether separately payable or packaged); this includes inpatient facility claims when separately payable.

0636required billing revenue code for drugs/biologicals

C9399used for unclassified drugs/biologics

Multipleexamples listed

AWP/CMSpricing methodology

Coverage and Billing Criteria for Drugs and Biologicals

Coverage and billing criteria

Coverage and billing stance for drugs and biologicals:

Hospital claims for drugs and biologicals must be billed with appropriate HCPCS codes when billed under revenue code 0636; applies whether items are separately payable or packaged and includes inpatient facility claims when separately payable.

EmblemHealth and ConnectiCare will align with CMS on which drugs and biologicals are considered routine (bundled) versus separately reimbursable and will follow CMS pass-through payment status changes.

On the claim, providers must report the total quantity administered (in the applicable unit), the National Drug Code (NDC), and the date administered.

Drugs/biologicals billed using HCPCS C9399 may be separately payable and are priced using Average Wholesale Price (AWP) and/or CMS pricing methodology based on the NDC submitted.

Policy Summary

PayerEmblemHealth

PolicyDrugs and Biologicals Payment Policy (Commercial, Medicare and Medicaid)

Policy CodePolicy RPC2O230040

Change TypeClarification — billing under revenue code 0636

Effective DateMar 1, 2024

Next Review Date

Key ActionProviders must report total quantity administered, the NDC, and the administration date on the claim and use the correct HCPCS codes for items billed.

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.

Not Otherwise Classified/Unlisted codes J3490 and J3590 are generally considered inclusive of acquisition cost and pharmacy (or nuclear medicine) handling overhead and are not separately payable except for identified pass-through high-cost authorized drugs.

Examples

Possible separately allowed drug categories include: drugs used with durable medical equipment; some antigens; injectable osteoporosis drugs; erythropoiesis-stimulating agents; blood clotting factors; injectable and infused drugs; parenteral and enteral nutrition; oral ESRD drugs; IVIG provided in the home; vaccinations; post-transplant immunosuppressives; oral cancer drugs; oral anti-nausea drugs; and self-administered drugs in the hospital outpatient setting.
Examples of routinely bundled drugs include IV fluids and additives (dextrose, lactated ringers, calcium), antibiotics, nitroglycerin, glycopyrrolate, and analgesic/anesthetic agents such as lidocaine, bupivacaine, and propofol.

Relevant HCPCS and Claim Data Requirements

Relevant HCPCS/Not Otherwise Classified codesHCPCS

C9399	Unclassified drug or biological (new drugs/biologics approved by FDA on/after 1/1/2004 without specific HCPCS code)
J3490	Not Otherwise Classified drug/biological (inclusive of acquisition and pharmacy overhead except pass-through high-cost drugs)
J3590	Unclassified biologics (similar handling as J3490)

Required claim data elements

Total quantity administeredTotal quantity of the drug administered, expressed in the unit of measure applicable to the drug or biological

NDCNational Drug Code (NDC) must be reported on the claim

Date administeredThe date the drug or biological was administered must be reported on the claim

Provider Billing and Reporting Requirements

Billing Rule

Claim reporting and coding requirements

On institutional claims billed under revenue code 0636, report the total quantity administered (in the drug's unit of measure), the National Drug Code (NDC), and the date the drug was administered; and bill the specific HCPCS code for the item(s) used (including C9399 when applicable).

Report total quantity of the drug administered, expressed in the unit of measure applicable to the drug.
Include the National Drug Code (NDC) on the claim.
Include the date the drug was administered.
Use the correct HCPCS code for items used; HCPCS C9399 is for new drugs/biologics approved by FDA on or after 1/1/2004 without an assigned specific HCPCS code.
Hospital claims billed under revenue code 0636 must be billed with the appropriate HCPCS whether items are separately payable or packaged; includes inpatient facility claims when separately payable.

Definitions: Separately Payable and Bundled

Separately payable — definition and examples

DefinitionDrugs and biologicals that may be billed and reimbursed separately from bundled facility charges when criteria are met; EmblemHealth/ConnectiCare will align with CMS determinations

ExamplesDrugs used with durable medical equipment, some antigens, injectable osteoporosis drugs, erythropoiesis-stimulating agents, blood clotting factors, injectable/infused drugs

Billing noteHospital claims for drugs and biologicals must be billed with the appropriate HCPCS codes when billed under revenue code 0636 (applies whether separately payable or packaged)

Bundled — definition and examples of routinely packaged drugs

DefinitionRoutinely packaged (bundled) drugs are those considered part of facility, surgical, or room-and-board charges and are not reimbursed separately

ExamplesIV fluids and additives (dextrose, lactated ringers, calcium), antibiotics, nitroglycerin, glycopyrrolate, analgesic anesthetics (e.g., lidocaine, bupivacaine, propofol)

Coding/pricing noteDrugs billed with unclassified HCPCS (C9399) may be separately payable and are priced using AWP and/or CMS pricing methodology based on the NDC submitted; J3490/J3590 are generally inclusive of acquisition and pharmacy overhead except identified pass-through high-cost drugs