24-432m Submit Claims With Valid National Drug Codes to Ensure Payment

Date: 04/30/24

National Drug Codes (NDC) required on all drug claims

As a reminder, Health Net requires the use of NDC and related information, such as Healthcare Common Procedure Coding System (HCPCS) and Current Procedural Terminology (CPT^®) codes, when drugs are billed on claims.

Providers should adhere to the NDC billing requirements to ensure submitted claims have all required information for timely claims processing. Claims without this information cannot be paid.

NDC billing requirements

NDC numbers are the industry standard identifier for drugs and provide full transparency about the medication administered. The NDC number encompasses essential details, including the manufacturer, drug name, dosage, strength, package size and quantity.

To qualify for reimbursement on forms such as the 1500 Health Insurance Claim Form (CMS-1500), 837-professional transaction, UB-04 Claim Form, or 837i facility transaction, the following NDC details must be provided:

• A valid NDC number.
• Unit of measure.
• Units dispensed for the administered drug.

How to resolve denied drug claims

If the NDC information is missing, invalid, incomplete, or does not match the HCPCS or CPT submitted, the claim may be denied. If the claim is denied, it can be resubmitted with the appropriate NDC information for reconsideration of reimbursement.

The following is a claims rejection reason, and possible resolutions.

Reject code	Reject reason	Requirements	CMS-1500 or UB-04
A5	NDC or UPIN information missing/invalid.	Providers must bill the Unique Physician Identification Number (UPIN) qualifier, number, quantity, and type or NDC qualifier, number, quantity, and unit/basis of measure. If any of these elements are missing, the claim will reject.	CMS-1500 box 24D UB-04 box 43

Resubmissions

Below are quick tips and general guidelines to assist you with proper submission of valid NDCs and related information on electronic and paper claims:

• The NDC must be submitted along with the applicable HCPCS/CPT code(s) and the number of HCPCS/CPT units.
• Include the NDC qualifier, number of NDC units and NDC unit of measure.
• The NDC must follow the 5 digit, 4 digit, 2 digit format (11-digit billing format, with no spaces, hyphens or special characters). If the NDC on the package label is less than 11 digits, a leading zero must be added to the appropriate segment to create a 5-4-2 configuration.
• The NDC must be active for the date of service.

Additional information

If you have questions regarding the information contained in this update, contact the applicable Health Net Provider Services Center at:
 

Line of business	Phone number	Email
IFP Ambetter PPO	844-463-8188	Email
IFP Ambetter HMO	888-926-2164	Email
Health Net Employer Group HMO, POS & PPO	800-641-7761	Email

 

This information applies to Physicians, Participating Physician Groups (PPGs), Hospitals, and Ancillary Providers.