IL BCBSIL NDC Billing Update for Medicare Advantage Claims

October 2017 ~

Effective December 15, Blue Cross and Blue Shield of Illinois (BCBSIL) will implement edits to validate National Drug Code (NDC)s that are submitted on electronic and paper, professional and institutional Blue Cross Medicare Advantage (PPO) and Blue Cross Medicare Advantage (HMO) claims.

The following 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.

Elements Required when NDC is Present on Electronic Claims:

  • Current Procedural Terminology (CPT®) or Healthcare Common Procedure Coding System (HCPCS) Code
    • Professional Electronic Claim (837P) Loops and Segments: Loop 2400, SV101-1 = HC; Loop 2400, SV101-2 = [CPT®/HCPCS code]
    • Institutional Electronic Claim (837I) Loops and Segments: 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
    • 837P Loops and Segments: Loop 2400, SV101-7
    • 837I Loops and Segments: Loop 2400, SV202-7
  • Line Item Charge Amount
    • 837P Loops and Segments: Loop 2400, SV102
    • 837I Loops and Segments: Loop 2400, SV203
  • Unit of Measurement Code
    • 837P Loops and Segments: Loop 2400, SV103 = UN
    • 837I Loops and Segments: Loop 2400, SV204 = UN
  • Service Unit Count
    • 837P Loops and Segments: Loop 2400, SV104
    • 837I Loops and Segments: Loop 2400, SV205
  • NDC Qualifier
    • 837P Loops and Segments: Loop 2410, LIN02 = N4
    • 837I Loops and Segments: Loop 2410, LIN02 = N4
  • NDC (11-character alpha-numeric value containing no spaces, hyphens or special characters)
    • 837P Loops and Segments: Loop 2410, LIN03 = NDC Number
    • 837I Loops and Segments: Loop 2410, LIN03 = NDC Number
  • Quantity/Dosage* (Number of NDC units)
    • 837P Loops and Segments: Loop 2410, CTP04
    • 837I Loops and Segments: Loop 2410, CTP04
  • Unit of Measure (UOM = UN, ML, GR or F2)
    • 837P Loops and Segments: Loop 2410, CTP05-1
    • 837I Loops and Segments: Loop 2410, CTP05-1
  • Prescription Number (when applicable)
    • 837P Loops and Segments: Loop 2410, REF01 = XZ; REF02 = [prescription number]
    • 837I Loops and Segments: Loop 2410, REF01 = XZ; REF02 = [prescription number]

The following NDC-related elements must be entered 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:

Elements Required when NDC is Present on Paper Claims:

  • Professional Paper Claim (CMS-1500) Fields and NDC-related Information:
    • 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) Form Locator Numbers and NDC-related Information:
    • 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

BCBSIL states these validation edits are being implemented to align with CMS encounter data submission requirements. Providers should confirm that the NDCs submitted on any claims are appropriate for services rendered and active for the date(s) of service billed.

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

 

Source(s): BlueCross BlueShield of Illinois Blue Review;

 

 

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