National Drug Code (NDC) Pricing Implementation Effective Nov. 1, 2013

July 10, 2013

Previous articles emphasized the importance of including NDCs and related data (qualifier, unit of measure, number of units, billable charge), along with the appropriate HCPCS or Current Procedural Terminology (CPT®)  code when drugs are billed on professional/ancillary electronic (ANSI 837P) and paper (CMS-1500) claims.

Earlier this year, an NDC pricing pilot was conducted to test effectiveness of system enhancements from a provider perspective. The pilot was successful and NDC pricing will be implemented for professional/ancillary claims with dates of service beginning Nov. 1, 2013. As of the Nov. 1, 2013, NDC pricing effective date, professional/ancillary claims for drugs must include NDC data in order to be accepted for processing by Blue Cross and Blue Shield of New Mexico (BCBSNM). 

NDCs provide a more accurate pricing methodology for payment. Use of the NDC will also facilitate better management of drug-associated costs. Other advantages of NDC pricing include:

  • NDCs/NDC units submitted by providers will be verified systematically
  • Pricing will be updated monthly, so providers will receive reimbursement that is reflective of market price
  • Providers will get paid for what was actually dispensed (instead of a range of NDCs within HCPCS codes) to ensure accuracy and consistency

While the BCBSNM claim system will automatically validate that an appropriate NDC was used relative to the HCPCS/CPT code, you will need to ensure that the correct number of NDC units is included, along with the billable charge and other required data.

Here are examples of resources that may be helpful in your transition to successful use of NDCs and related information:

  • Answers to NDC Frequently Asked Questions are available in the Claims and Eligibility/Submitting Claims section of our website.
  • Refer to the NDC billing guidelines in the Blues Provider Reference Manual, Section 8 – Claims.
  • Registered Availity® users also may access an NDC Units Calculator Tool, which is available under Claims Management upon logging in to the Availity provider portal. If you are not yet registered with Availity, we encourage you to visit their website at . Registration is free and gives you access to a variety of electronic applications offered through Availity for BCBSNM network providers.

Please watch upcoming issues of the Blue Review as well as the News and Updates section of our Provider website at for additional information on pharmacy optimization and other important initiatives at BCBSNM.

CPT copyright 2012 American Medical Association (AMA). All rights reserved. CPT is a registered trademark of the AMA.

Availity is a registered trademark of Availity, LLC. Availity is a partially owned subsidiary of Health Care Service Corporation, a Mutual Legal Reserve Company (HCSC), an independent licensee of the Blue Cross and Blue Shield Association. Availity operates a health information network to provide electronic information exchange services to medical professionals. Availity provides administrative services to BCBSNM, a Division of HCSC. Availity is solely responsible for the products and services it provides.

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