New NDC daily quantity maximum messaging begins in January for professional providers

The daily quantity maximum is the number of units a National Drug Code can be billed on a single claim line for a particular date. Starting Jan. 1, 2016, when an NDC reaches or goes over its daily quantity maximum, professional providers will receive a new message on your provider voucher:

We can pay for this service, but our payment policy has limits for this National Drug Code. This drug claim has a daily quantity maximum that’s more than we can pay. We’ve based our payment and the member’s liability on the eligible limit amount. (P610)

For example, if an NDC’s quantity maximum is five per date of service and 15 are coded, the message will also say that there’s been an adjustment in the reimbursement. Payment will be made for the first five units only.

A participating professional provider shouldn’t ask the member to pay more than the amount we allow.

This message doesn't apply to outpatient hospitals because these providers aren't required to submit claims at the NDC level.