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National Drug Code (NDC) Billing Update for Medicare Advantage Claims

September 14, 2017

Beginning Dec. 15, 2017, Blue Cross and Blue Shield of New Mexico (BCBSNM) will activate edits to validate NDCs that are submitted on electronic and paper professional and institutional Blue Cross Medicare Advantage (PPO)SM and Blue Cross Medicare Advantage (HMO)SM claims. These validation edits are being implemented to align with the Centers for Medicare & Medicaid Services (CMS) encounter data submission requirements. Providers should confirm that the NDCs submitted are appropriate for services rendered and active for the date(s) of service billed.

The table below specifies which NDC-related elements must be entered if NDCs are included on electronic professional and institutional claims for Medicare Advantage members. Claims submitted containing NDCs may be rejected if any of these data elements are missing or incorrect. Rejected claims must be resubmitted with the correct data. If you use a billing service or clearinghouse, please share the above information with your vendor.

Elements Required when NDC is Present on Electronic Claims

Professional Electronic Claim (837P) Loops and Segments

Institutional Electronic Claim (837I) Loops and Segments

Current Procedural Terminology (CPT®) or Healthcare Common Procedure Coding System (HCPCS) Code

Loop 2400, SV101-1 = HC

 

Loop 2400, SV101-2 = [CPT/HCPCS code]

Loop 2400, SV202-1 = HC

Loop 2400, SV202-2 = [CPT/HCPCS code]

If the CPT/HCPCS code in SV101-2 (professional claim) / SV202-2 (institutional claim) is an unlisted procedure code or Not Otherwise Classified (NOC)” code, a description is required

Loop 2400, SV101-7

Loop 2400, SV202-7

Line Item Charge Amount

Loop 2400, SV102

Loop 2400, SV203

Unit of Measurement Code

Loop 2400, SV103 = UN

Loop 2400, SV204 = UN

Service Unit Count

Loop 2400, SV104

Loop 2400, SV205

NDC Qualifier

Loop 2410, LIN02 = N4

Loop 2410, LIN02 = N4

NDC (11-character alpha-numeric value containing no spaces, hyphens or special characters)

Loop 2410, LIN03 = NDC Number

Loop 2410, LIN03 = NDC Number

Quantity / Dosage* (Number of NDC units)

Loop 2410, CTP04

Loop 2410, CTP04

Unit of Measure (UOM = UN, ML, GR or F2)

Loop 2410, CTP05-1

Loop 2410, CTP05-1

Prescription Number (when applicable)

Loop 2410, REF01 = XZ

REF02 = [prescription number]

Loop 2410, REF01 = XZ

 

REF02 = [prescription number]

If NDCs are submitted on paper professional (CMS-1500) and institutional (UB-04) claims for Medicare Advantage members, the following NDC-related elements must be included: 

Professional (CMS-1500) fields

  • 24A – (shaded area) – NDC Qualifier, NDC 11-digit number, Unit of Measure Qualifier and Unit Quantity
  • 24D – CPT/HCPCS code
  • 24G – HCPCS unit

Institutional (UB-04) fields

  • 42 – Revenue code
  • 43 – Revenue Code Description, NDC Qualifier, NDC 11-digit number, Unit of Measure Qualifier and Unit Quantity
  • 44 – HCPCS code
  • 45 – Service/Assessment Date
  • 46 – Service Units

*For assistance with calculating the number of NDC units, independently contracted BCBSNM providers may access the NDC Units Calculator Tool via the Availity™ Web Portal.

For additional claim-related information, refer to the appropriate Provider Manual in the Standards and Requirements section of our website at bcbsnm.com/provider. As always, your assigned BCBSNM Provider Network Representative is available to provide personalized assistance to you and your staff.

CPT copyright 2016 American Medical Association (AMA). All rights reserved. CPT is a registered trademark of the AMA.

Availity is a trademark of Availity, LLC, a separate company that operates a health information network to provide electronic information exchange services to medical professionals. Availity provides administrative services to BCBSNM. BCBSNM makes no endorsement, representations or warranties regarding any products or services offered by third party vendors such as Availity. If you have any questions about the products or services offered by such vendors, you should contact the vendor(s) directly.

Blue Cross and Blue Shield of New Mexico, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association.

Blue Cross®, Blue Shield® and the Cross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans.