Physician-Administered Drugs - NDC
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Governs National Drug Code (NDC) billing and related requirements for physician‑administered drugs billed to Health Plan of San Joaquin; affects providers submitting claims (physician offices, clinics, hospitals) for covered outpatient drugs.
No material clinical or coverage changes in this revision.
NDC Billing and Coverage Criteria
NDC billing and coverage criteria
Coverage and billing stance for physician‑administered drugs regarding NDC reporting, transitional allowances, exclusions, and special categories. Covered when the following conditions are met:
ALL of the following
ALL of the following
- For claims with dates of service on or after 2009-04-01, a valid NDC paired with a HCPCS code is required; claims without the NDC for dates on/after this date will be denied.
- Claims with dates of service from 2008-09-01 through 2009-03-31 may be submitted without an NDC (accepted).
ALL of the following
- The NDC submitted on the claim must be the NDC printed on the package or container from which the medication was administered.
- Do not bill an NDC for a product different from the drug actually administered; billing a different manufacturer's NDC is considered fraudulent billing.
Exclusions (ONE of)
- Vaccines are exempt from the federal rebate requirement and therefore are excluded from the NDC reporting requirement.
- Bulk drugs (Active Pharmaceutical Ingredients, APIs) are not reimbursable; payment for bulk drugs is not allowed.
ALL of the following
- A physician-administered drug is any covered outpatient drug provided or administered to a recipient and billed by a provider (not self-administered), including injectable and non-injectable drugs.
Codes and Submission Dates
Provider Billing Requirements and References
NDC required on claims for services on/after 04/01/2009 — denial risk
Claims with dates of service on or after April 1, 2009 must include a valid NDC paired with a HCPCS code; claims submitted for dates of service from September 1, 2008 through March 31, 2009 without an NDC are acceptable. Claims that do not include a valid NDC paired with a HCPCS code for dates of service on or after April 1, 2009 will be denied. The NDC submitted on the claim must match the NDC on the drug container; billing a different manufacturer's NDC than the drug administered is considered fraudulent.
- Providers encouraged to begin billing with an NDC beginning September 1, 2008 (transitional allowance through March 31, 2009).
- Claims on/after 04/01/2009 require a valid NDC paired with a HCPCS or they will be denied.
- The NDC on the claim must match the NDC on the package/container actually administered; billing a different manufacturer's NDC is fraudulent.
Follow CMS-1500 and UB-04 completion instructions
For detailed claim form completion instructions, refer to the CMS-1500 and UB-04 billing instruction sections in the Part 2 manual (CMS-1500 Completion; UB-04 Completion: Outpatient Services; UB-04 Completion: Inpatient Services).
- See 'Physician-Administered Drugs -NDC: CMS-1500 Billing Instructions' and 'Physician-Administered Drugs -NDC: UB-04 Billing Instructions' in Part 2 manual.
Key Definitions
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