Blue Cross professional providers may get new messages regarding medical drug claims for commercial members

Starting in October, Blue Cross Blue Shield of Michigan professional providers may receive a new informational message when a medical drug claim line is billed incorrectly as it relates to the National Drug Code or the HCPCS code. For example, we may have determined that:

• Reimbursement should be at the HCPCS level.
• Reimbursement should be at the HCPCS level and the HCPCS units billed were over our daily quantity maximum.
• Reimbursement should be at the NDC level and the NDC units billed were over our daily quantity maximum.

Following is a look at the messages and when you may receive them.

When a National Drug Code is billed with an incorrect HCPCS combination or unit conversion, you’ll receive this new message on your provider voucher:

WE WERE NOT ABLE TO MATCH THE HCPCS AND NDC TO EACH OTHER OR CONVERT THE NDC UNITS TO THE HCPCS UNITS BILLED. WHEN BILLING MEDICAL DRUG CLAIMS, REPORT THE NDC AND NDC UNITS THAT ARE APPROPRIATE TO THE HCPCS AND HCPCS UNITS BILLED, OTHERWISE REIMBURSEMENT MAY NOT BE AT THE LEVEL YOU EXPECTED. (P660)

When a National Drug Code is billed with an incorrect HCPCS combination or unit conversion and the NDC unit reaches or exceeds its daily quantity maximum, you’ll receive a new message on your provider voucher:

THE NDC UNITS AND HCPCS UNITS SUPPLIED, BASED ON OUR CALCULATIONS, ARE NOT A MATCH. WHEN BILLING MEDICAL DRUG CLAIMS, REPORT THE NDC AND NDC UNITS THAT ARE APPROPRIATE TO THE HCPCS AND HCPCS UNITS BILLED, OTHERWISE REIMBURSEMENT MAY NOT BE AT THE LEVEL YOU EXPECTED. THIS DRUG CLAIM HAS A NDC QUANTITY THAT'S MORE THAN WE CAN PAY. WE BASED OUR PAYMENT, AND THE MEMBER'S LIABILITY, ON THE AMOUNT FOR THE ELIGIBLE LIMIT. A PARTICIPATING PROVIDER SHOULD NOT ASK THE MEMBER TO PAY MORE THAN THE AMOUNT WE ALLOWED. WHEN OTHER PROVIDERS PERFORM THIS SERVICE, THE MEMBER MIGHT OWE ANY AMOUNT NOT PAID BY THE HEALTH CARE PLAN.  (P667)

When a National Drug Code is billed with an incorrect HCPCS combination or unit conversion and the HCPCS unit reaches or exceeds its daily quantity maximum, you’ll receive a new message on your provider voucher:

WE WERE NOT ABLE TO MATCH THE HCPCS AND NDC TO EACH OTHER. PLEASE CHECK TO MAKE SURE THE NDC CODE IS APPROPRIATE FOR THE HCPCS BILLED AND THE UNITS FOR EACH ARE CORRECT, OTHERWISE REIMBURSEMENT MAY NOT BE AT THE LEVEL YOU EXPECTED. THIS DRUG CLAIM HAS A HCPCS QUANTITY THAT'S MORE THAN WE CAN PAY. WE BASED OUR PAYMENT, AND THE MEMBER'S LIABILITY, ON THE AMOUNT FOR THE ELIGIBLE LIMIT. A PARTICIPATING PROVIDER SHOULD NOT ASK THE MEMBER TO PAY MORE THAN THE AMOUNT WE ALLOWED. WHEN OTHER PROVIDERS PERFORM THIS SERVICE, THE MEMBER MIGHT OWE ANY AMOUNT NOT PAID BY THE HEALTH CARE PLAN.  (P668)

These messages don’t apply to outpatient hospital providers because these providers aren't required to submit claims at the NDC level unless they’re submitting a Not Otherwise Classified Code.