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1 Louisiana Medicaid National Drug Code (NDC) Transitional Requirements for Claims Submission On-Line Webinar February 3-6, 2009.

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Presentation on theme: "1 Louisiana Medicaid National Drug Code (NDC) Transitional Requirements for Claims Submission On-Line Webinar February 3-6, 2009."— Presentation transcript:

1 1 Louisiana Medicaid National Drug Code (NDC) Transitional Requirements for Claims Submission On-Line Webinar February 3-6, 2009

2 2 NATIONAL DRUG CODE (NDC) IMPLEMENTATION Federal Statute Enacted in January 2008 Requires the Use of NDC on Claims for Physician Administered Drugs Most Providers Billing for Physician Administered Drugs MUST Enter the Drug NDC and Other Required Information on Claims ► Physician ► Outpatient Hospital ► Licensed Hemodialysis Centers

3 3 PROVIDERS EXCLUDED FROM THIS NDC IMPLEMENTATION Rural Health Clinics Federally Qualified Health Centers Mental Health Clinics Providers that bill all-inclusive services and are paid encounter rates

4 4 PHYSICIAN ADMINISTERED DRUGS Physician-Administered Drugs Include Any Drugs Ordered by a Doctor (APRN or PA With Prescriptive Authority) Regardless of Which Clinical Professional Actually Administers the Drug

5 5 RECORDS REQUIREMENTS AND RETENTION Drugs Will Be Invoiced to Drug Manufacturers for Medicaid Rebates LA Medicaid Will Audit/Review These Claims Upon Manufacturer Request or if Outlier Billing Detected Providers Must Retain All Records for 5 Years From Date of Service OR Until Conclusion of All Audit Questions/Disputes/Review Issues

6 6 RECORDS REQUIREMENTS AND RETENTION May Request Copies of Office Records Including Documents Pertaining to Billed HCPCS/NDC Codes May Include Drug/NDC Invoices for Purchase of Drugs; Documentation of Drug Administered Including Name/Strength/Amount/Date and Copies of Labels from Drug Packages* *These are examples of what the provider may present as proof of the NDC used. If the provider has invoice records, copies of labels are not necessary but may be requested if available from drugs on hand.

7 7 DELAY IN IMPLEMENTATION OF CLAIM DENIALS INITIALLY, Claim Denials Were To Be Effective With Processing Date July 1, 2008 Denial Edits Were Postponed to Assist Providers with Preparing for the Transition Educational Edits were Implemented Effective With Date of Service March 1, 2008 and Continue to be Educational

8 8 NEW NDC IMPLEMENTATION DATE FOR PHYSICIAN, OUTPATIENT HOSPITAL & HEMODIALYSIS CENTER CLAIMS EFFECTIVE WITH PROCESSING DATE April 1, 2009,CLAIMS WILL DENY IF NDC INFORMATION IS NOT PRESENT APPLIES TO BOTH EDI & HARD COPY/PAPER CLAIMS - Must have both NDC Data & Procedure/HCPCS Code - Must be correctly entered on the claim

9 9 REQUIRED NDC DATA Required Data Must Be Entered EXACTLY As Indicated In Billing Instructions To Prevent Denials REMINDER: Both EDI and Hard Copy/Paper Claims To view the CMS 1500 Professional Billing Instructions, click on the link below: To view the UB04 Hospitals Billing Instructions, click on the link below: To view the UB04 Hemodialysis Billing Instructions, click on the link below: To view the 837 Professional EDI Companion Guide, click on the link below: To view the 837 Institutional EDI Companion Guide, click on the link below:

10 10 REQUIRED NDC DATA EDI Claim Data

11 11 REQUIRED NDC DATA Paper Claim Instructions NDC Data - Qualifier N4 Followed by the NDC - Do Not Enter a Space Between Qualifier & NDC - Do Not Enter Hyphens or Spaces Within NDC - Leave 1 Space - Enter Appropriate Unit Qualifier and Actual Units Given - Leave 3 Spaces - Enter Brand Name As Written Description In Remaining Spaces (Not applicable for UB-04) HCPCS Code Applicable for NDC Data Claim Form Examples Presented on Slides 15, 16, & 17

12 12 IMPLEMENTATION FOR OUTPATIENT HOSPITAL BILLING - Duplicate Edit Logic Lifted to Accommodate Multiple Entries of Revenue Codes 250 & 636 Without Denying as a Duplicate Examples (Paper Claim Sample) : When 2 or more Drugs or 2 or more NDCs are reported with revenue code 250 or 636, enter individual claim lines with revenue code 250 or 636 and the corresponding NDC and Procedure Code: Ex #1: 250N U N J N U N L2000 Ex #2: 636 N U N J N U N L2000

13 13 ELECTRONIC CLAIMS TRANSMISSION Electronic (EDI) Transmission of Claims is the Preferred Method for Submitting Claims Medicaid Encourages this Method which Eliminates Data Entry of Claims and Expedites Processing and Payment of Claims Acceptable EDI Vendors, Billing Agents, and Clearinghouses are found in the VBC List Located on the LA Medicaid Web Site link below. The List is Updated Monthly.

14 14 Claim Edits for NDC Edit 127 NDC Code Missing or Incorrect Edit 231 NDC Code Not on File Edit 120 Quantity Invalid/Missing

15 15 CMS 1500 CLAIM EXAMPLE

16 16 UB-04 CLAIM EXAMPLE FOR OUTPATIENT HOSPITAL SERVICES

17 17 UB-04 CLAIM EXAMPLE FOR HEMODIALYSIS CENTER SERVICES SAMPLE ONLY. FOR EXAMPLE.

18 18 MEDICARE REQUIREMENTS Providers should refer to the CMS web site and other sites below for information concerning Medicare requirements. In order to capture the information needed to fulfill the rebate requirements for State Medicaid Agencies, CMS issued Change Request (CR) 5950 for Medicaid drug rebate information to be entered on paper claims for submission to Medicare for beneficiaries dually eligible for Medicare and Medicaid. ingResources/downloads/JA5835.pdf ingResources/downloads/JA5835.pdf cles/downloads/MM5950.pdf cles/downloads/MM5950.pdf

19 19 PAYMENT REMINDERS For All Claims Reporting Physician Administered Drugs – Processing Date for Implementation of Claim Denials = April 1, 2009 – Must Report All Required Information – Must Be Entered EXACTLY As Indicated – Applies To Both EDI and Paper Claims – Records Related to Services Must Be Kept for 5 Years From Date of Service or Until Audit Conclusion – Must Supply Records When Requested by DHH

20 20 GENERAL REMINDERS – Frequently Asked Questions (FAQ) Posted on Web – Provider Notices Posted on Web

21 21 CONTACT INFORMATION Unisys Provider Relations Department Phone: (800) (225)

22 22 Questions & Answers As you exit from the presentation, please wait to take the short survey before disconnecting from the web site.


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