Health Care Reform legislation initiated changes to utilization reporting requirements for Medicaid Managed Care Organizations. The new reporting requirements impact rebates issued by drug manufacturers to the Texas Health and Human Services Commission (HHSC). To comply with the legislation, providers are required to submit claims for provider administered medications using National Drug Codes (NDCs), Unit of Measurement, and Quantity of Unit. The NDC is a unique 11-digit, 3-segment numeric identifier assigned to each medication listed under Section 510 of the U.S. Federal Food, Drug, and Cosmetic Act.
This is a reminder of how to submit claims for physician administered medications dispensed to Texas Medicaid STAR, CHIP, and STAR Kids members by professional providers in the outpatient setting. In addition to drugs, long acting reversible contraceptives such as intra uterine devices (IUDs), hormone patches, vaginal rings, and sub dermal implants are included as well as intra uterine copper device.
NDCs with fewer than 11 digits are missing a digit from one of the 5-4-2 segments. This is easily corrected by inserting a zero for the missing digit. Below are some helpful examples.
Examples of NDCs with fewer than 11-digits and solutions for converting them using zeroes
0002-7597-01 Zyprexa® 10mg vial
Problem: A digit is missing from the first segment. It should have five digits to be in the required 5-4-2 format.
Solution: Adding a zero to the first segment converts the NDC into the correct format.
50242-040-62 Xolair® 150mg vial
Problem: A digit is missing from the second segment. It should have four digits to be in the required 5-4-2 format.
Solution: Adding a zero to the second segment converts the NDC into the correct format.
If there is more than one NDC within the Healthcare Common Procedure Coding System (HCPCS) code, submit each applicable NDC as a separate claim line. Each drug code submitted must have a corresponding NDC.
If a drug is comprised of more than one ingredient, such as a compound drug or the same drug in a different strength, each NDC must be entered using the same drug code.
Use one of the following modifiers accepted by standard HCPCS billing when more than one NDC is billed for a service code:
KP — First drug of a multiple drug unit dose formulation
KQ — Second or subsequent drug of a multiple drug unit dose formulation
SH — Second or concurrently administered infusion therapy
SJ — Third or more concurrently administered infusion therapy
If you have any questions, please contact the Customer Service at 1-877-560-8055.