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November 2014

Be sure to include prescriber’s NPI on Medicare Part D claims

Based on new requirements from the Centers for Medicare & Medicaid Services, pharmacies must include the prescriber’s NPI in field 411-DB of the NCPDP claim when submitting Medicare Part D claims.

Pharmacies that currently submit claims using Drug Enforcement Administration numbers or state license numbers for Medicare claims should adjust their practice to accommodate this change. If you submit anything other than the prescriber’s NPI in field 411-DB, you’ll receive rejection code 25 (M/I prescriber ID).

As a reminder, CMS expects pharmacies to resolve any rejections related to an invalid prescriber within 24 hours without causing a disruption to the member. Claims submitted with a Submission Clarification Code will be subject to post-adjudication review and may be reversed if a valid prescriber NPI cannot be obtained or a DEA number is found to not allow the drug DEA schedule.

Where to call for help

For help with prescription drug claims: Call the Express Scripts Pharmacy Technical Help Desk at 1-800-922-1557. The help desk is staffed 24 hours a day, seven days a week.

For prior authorization or step therapy questions, coverage determinations and other exceptions: Call the Blues Clinical Help Desk at 1-800-437-3803 from 8 a.m. to 6 p.m. Monday through Friday.

Note: Members can call the customer service number on the back of their ID cards.

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*CPT codes, descriptions and two-digit numeric modifiers only are copyright 2013 American Medical Association. All rights reserved.
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