Highmark List of Procedure Codes Requiring NDC
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A Highmark Pennsylvania reimbursement/policy list identifying HCPCS/CPT procedure codes that require submission of an NDC (National Drug Code) effective 07/01/2024; applies to providers billing Highmark Pennsylvania for the listed injectable/oral drug administrations.
No material clinical or coverage changes in this revision.
Procedure Codes Requiring NDC — Coverage Criteria
inv-01: Codes requiring NDC (partial list)
The following HCPCS / J-codes require submission of the corresponding National Drug Code (NDC) on the claim when billed to Highmark Pennsylvania (partial list).
inv-02: NDC submission requirement
When submitting claims for the HCPCS/J procedure codes listed below, the claim must include the corresponding NDC.
inv-03: NDC submission requirement (billing rule)
Billing rule: for the specific HCPCS/Q/J codes shown, providers must report the product NDC on the claim.
Example entries (partial)
inv-04: Product-specific eligibility snippets
Product-specific eligibility notes where provided in the list.
Operational note: ensure NDC is reported on the claim for these prophylaxis products in addition to confirming patient age and weight eligibility as specified.
Code Lists and Examples
Billing Requirements and Actions for Providers
NDC Submission Requirement — Listed Procedure/HCPCS/J Codes
Providers must submit the National Drug Code (NDC) when billing any of the procedure/HCPCS/J codes listed below. Failure to report the NDC may result in claim processing delays or denial. This requirement is effective 07/01/2024.
- Effective 07/01/2024: Submit NDC on all claims for the listed procedure/HCPCS/J codes.
- Include product NDC, unit of measure, and number of units consistent with the billed code and dosing.
NDC Requirement for Listed Procedure Codes
Providers must report the NDC for the following HCPCS/J procedure codes when submitting claims. The Highmark List of Procedure Codes Requiring NDC (effective 07/01/2024) includes, but is not limited to, the codes shown across this policy. Always reference the full Highmark code list when preparing claims.
- Examples of included codes (partial list): 90378, C9399, J0121, J0122, J0129, J0130, J0135, J0153, J0172, J0177, J1571, J1572, J1595, J1602, J1627, J7294, J9354, J9355, J9356, J9358, J9360, J9370, J9371, J9380, J9381, J9390, J9395, J9400, J9600, J9999, Q0138, Q0139, Q0166, Q0167, Q0180
- Providers should consult the complete Highmark list in this policy for all codes requiring NDC submission.
COVID-19 Monoclonal Antibody and Prophylaxis NDC Requirement
For COVID-19 monoclonal antibodies and COVID-19 prophylaxis agents, providers must submit the NDC for the listed Q-codes and related HCPCS drug codes when billing. This includes pre-exposure prophylaxis agents and COVID-19 monoclonal antibody treatments — submit the NDC to ensure correct benefit/administration adjudication.
- COVID-19 related codes requiring NDC (examples): Q0220, Q0221, Q0222, Q0224, Q0239 (and any other COVID-19 monoclonal antibody or prophylaxis HCPCS/Q-codes on the Highmark list).
- These requirements apply to agents used for pre-exposure prophylaxis and monoclonal antibody treatment; include the specific product NDC and dosage for each billed unit.
- Effective date: 07/01/2024 — submit NDC information on all claims for these COVID-19 related codes.
Definitions and Notes
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