CurrentPremera BluecrossPolicy N/A

Drugs & Biologics (D&B) claim edits for drugs administered in physician office or outpatient facility

This policy governs claim edit implementation for drugs and biologics administered in physician offices or outpatient facility clinics and processed under members' medical benefits for Premera Blue Cross and affiliated lines of business.

Policy Summary

PayerPremera Bluecross

PolicyDrugs & Biologics (D&B) claim edits for drugs administered in physician office or outpatient facility

Policy CodePolicy N/A

Change TypeAdded facility editsrevised policy title and statement

Effective DateDec 5, 2025

Next Review Date

Key ActionProviders must bill administered drugs/biologics with an appropriate HCPCS procedure code and an active NDC to be considered for reimbursement.

SourceLink

POLICY UPDATE CHANGES

D&B claim edits will also be applied to drugs/medications which are administered in an outpatient facility setting and which are processed under the member's medical benefits.

Revised Policy Title and revised the Policy statement to include D&B edits applied to drugs and medications billed on a facility claim.

multipleLines of business

Dec 5, 2025Effective date for facility edits

08/04/25Last approval

2018–2025Review history

Coverage and Reimbursement Criteria

Coverage criteria for D&B edits

Coverage and reimbursement are subject to member eligibility, benefit limits, Plan medical policies, and claim adjudication edits. Reimbursement requires correct coding and NDC submission.

All administered drugs/biologics must be billed with an appropriate HCPCS procedure code and an active National Drug Code (NDC) number to be considered for reimbursement.

D&B claim edits use criteria established by the U.S. Food and Drug Administration (FDA) package insert and other nationally recognized drug information sources (e.g., Lexicomp/Lexi-Drugs, Micromedex DRUGDEX, Medi-Span, RJ Health, AHFS, NCCN).

D&B claim edits apply to drugs/biologics administered in physician offices or outpatient clinic settings and to drugs/medications administered in outpatient facility settings for claims with dates of service on or after December 5, 2025.

Providers should follow cross-referenced Payment Policies for instructions on billing NDCs and use of modifiers JW (amount discarded) and JZ (zero drug amount discarded) for administered or wasted portions.

Policy Summary

PayerPremera Bluecross

PolicyDrugs & Biologics (D&B) claim edits for drugs administered in physician office or outpatient facility

Policy CodePolicy N/A

Change TypeAdded facility editsrevised policy title and statement

Effective DateDec 5, 2025

Next Review Date

Key ActionProviders must bill administered drugs/biologics with an appropriate HCPCS procedure code and an active NDC to be considered for reimbursement.

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 Codes, Modifiers, and Effective Dates

Required codes and modifiersmixedCovered

HCPCS series	Appropriate HCPCS procedure code required for administered drug/biologic
NDC	Active National Drug Code required on claim
Modifier JW	Amount discarded; not administered to any patient
Modifier JZ	Zero drug amount discarded; not administered to any patient

Effective date for outpatient facility inclusion

Effective dateClaims with dates of service December 5, 2025 and after

ScopeApplies to drugs/medications administered in outpatient facility settings processed under the member's medical benefits

Lines of businessPremera Blue Cross, Premera BCBS Alaska, LifeWise Health Plan of Washington, LifeWise Assurance Company, Premera Blue Cross HMO

ApplicationD&B claim edits will be applied to outpatient facility drug/medication claims in the same manner as those administered in physician offices or outpatient clinics

Authority for editsEdits use FDA package insert criteria and other nationally recognized drug information sources (e.g., Lexicomp, Micromedex, Medi-Span, RJ Health)

Billing, Submission, and Provider Requirements

Billing Rule

Bill with HCPCS procedure code and active NDC; use JW/JZ as applicable

All administered drugs/biologics must be billed with an appropriate HCPCS procedure code and an active National Drug Code (NDC) number to be considered for reimbursement; follow cross-referenced Payment Policies for guidance on correctly billing NDCs and using modifiers JW/JZ for wasted/zero drug amounts.

Bill administered drug/biologic with an appropriate HCPCS series procedure code.
Include an appropriate, active NDC on the claim.
Use modifier JW for amount discarded (wasted portion) and modifier JZ for zero drug amount discarded where applicable.
Refer to the Payment Policies in the Cross Reference section for detailed NDC and modifier billing guidelines.

Key Definitions

Drugs & Biologics (D&B) claim edits definition

DefinitionDrugs & Biologics (D&B) claim edits are automated claim editor checks that apply clinical and billing criteria to administered drugs/biologics billed under medical benefits

Clinical sourcesCriteria are established using FDA package inserts (manufacturer prescribing information) and supported by the Plan's Medical or Pharmacy Policies

Drug information sourcesOther nationally recognized sources include Lexicomp, Micromedex DRUGDEX, Medi-Span, RJ Health

Billing criteriaAll drugs/biologics administered must be billed with an appropriate HCPCS series procedure code and an active NDC to be considered for reimbursement

Scope of applicationApplies to drugs/biologics administered in physician offices, outpatient clinics, and outpatient facility settings processed under medical benefits