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Medication Billing and Coverage Updates

June 24, 2019

We previously announced a requirement to list a National Drug Code (NDC) on claims for J-codes. We have suspended this requirement and are revising it.

Effective October 1, 2019, any professional, ancillary or institutional outpatient claim for a J-code must also include the valid NDC of the billed product.

Details of this requirement:

This applies to:

  • Classified and unclassified (NOC) J-codes
  • Electronic and paper claim submissions for J-codes

- The NDC must correspond with the Healthcare Common Procedure Coding System (HCPCS)

- As there are often several NDCs linked to a single HCPCS code, each NDC must be submitted on a separate claim line even if the HCPCS code is the same

- If the required NDC information is not included on claims submitted on or after October 1, 2019, your claim will be rejected

- The temporary suspension of the requirement occurred on June 20, 2019

You may resubmit any rejected claims without an NDC before October 1, 2019. Starting on October 1, 2019, please include a valid NDC on any claims for J-codes.

Additional Drug Therapy Guidelines Updated

More than 110 additional drug therapy guidelines were recently added or updated with a committee of local physicians, other prescribers, and pharmacists. Changes to existing Drug Therapy Guidelines will be posted on our website by July 15, 2019, and will be effective August 15, 2019.  Guidelines around coverage of newly FDA-approved medications will be posted by July 15 and may be effective immediately. 

Please refer to these new and updated guidelines when discussing treatment options with your Blue Shield of Northeastern New York patients.

If you do not have access to the internet, you may request a paper copy by calling Provider Service at 1-800-444-4552 or (518) 220-5620

View List of New and Updated Guidelines

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