Drug claims require NDC numbers

All claim lines for drug HCPCS or CPT codes on outpatient claims must include a National Drug Code (NDC). The NDC is an 11-digit number that identifies the specific drug dispensed.

Drug claim lines submitted without an NDC, with an invalid or discontinued NDC, or with an incorrect HCPCS/CPT and NDC combination will be denied. For Medicaid, the drug NDC must be included in the Medicaid Drug Rebate Program (MDRP) on the date of service to be payable.  

Drugs that have not been assigned a drug-specific billing code must be billed with the appropriate Not Otherwise Classified (NOC) code. Be sure to provide the name of the drug, 11-digit NDC and the dosage dispensed. Providing an invoice is not always needed if you provide this information. 

See information below for how to enter NDC information on electronic transactions and paper claims. 

When an NDC is not required

An NDC does not need to be included when the drug dispensed is not separately payable (i.e., payment is grouped or bundled into reimbursement of a different service code on the claim).

Formatting the NDC on the claim

You must enter the NDC in an 11-digit billing format ( see below; no spaces, hyphens or other characters).

If the NDC on the package label is less than 11 digits, you must add a leading zero to the appropriate segment to create a 5-4-2 configuration.

Up-front rejections

Missing or invalid NDCs will result in an up-front rejection. Rejection messages for invalid NDCs include:

• Line Number XX, Missing NDC for HCPCS Code XXXXX
• Line Number XX, Invalid HCPCS Code XXXXX and/or NDC XXXXXXXXXXX

Electronic ANSI 5010 837P and 8371 transactions

Here are general guidelines for including NDC data in an electronic claim:

• Product ID Qualifier field: Enter N4, loop ID 2410, segment LIN02
• National Drug Code field: Enter the 11-digit NDC billing format assigned to the drug administered, loop ID 2410, segment LIN03
• National drug unit count: Enter the quantity (no. of NDC units), loop ID 2410, segment CPT04
• Unit or basis for measurement: Enter the NDC unit of measure for the drug given, loop ID 2410, segment CTP05

Include the total charge amount for each line of service for the Monetary Amount in Loop ID 2400, Segment SV102 (professional claims) or SV203 (facility claims).

Entering NDC data on paper claims

CMS-1500

1. In fields 24A-24G, in the shaded section above the procedure code, enter NDC qualifier N4 (left-justified), then one space for separation, then the NDC. 
2. Enter the qualifier (UN, ML, GR or F2) for the correct dispensing NDC unit of measure.
3. Enter the quantity (number of NDC units). Priority Health allows up to three decimals in the NDC units (quantity or number of units) field.

UB04

1. Enter NDC in locator (box) 43, labeled "Description." 
2. Enter the qualifier (UN, ML, GR or F2) for the correct dispensing NDC unit of measure. 
3. Enter the quantity (number of NDC units). Priority Health allows up to three decimals in the NDC units (quantity or number of units) field.