Update: Government Providers, Resubmit Claims Previously Incorrectly Rejected for Invalid NDCs
Posted August 2, 2019 (Updated August 20, 2019)
During post change monitoring for claims received on or after July 25, 2019, Blue Cross Blue Shield of Illinois (BCBSIL) noticed some inconsistencies as it relates to ‘OBSOLETE’ NDC codes in the MediSpan® database. On Aug. 13, 2019 at 3 p.m. CT (4 p.m. ET), BCBSIL implemented a coding change to correct this check of the MediSpan® database in our logic for obsolete NDCs. Please see the bolded update below under ‘Summary of change and compliant submission requests.’
BCBSIL will continue to monitor performance as it relates to this issue and will continue to work with Illinois Healthcare and Family Services (HFS) to validate obsolete codes from the MediSpan® database within the core adjudication system as needed.
If you feel any claims submitted and failed incorrectly between July 25, 2019 and Aug. 13, 2019, you may resubmit those claims following the guidance in the ‘What You Need to Do’ section below.
This notice applies to providers submitting electronic claims for the following Blue Cross and Blue Shield of Illinois (BCBSIL) members:
- Blue Cross Community Health PlansSM (BCCHPSM)
- Blue Cross Community MMAI (Medicare-Medicaid Plan)SM
BCBSIL has worked with the Illinois Healthcare and Family Services (HFS) to confirm that we have the correct National Drug Codes (NDCs) validation process in place so claims with compliant codes are received and processed correctly.
BCBSIL has updated its systems based on directions from HFS and as of July 25, 2019, BCBSIL is prepared to accept any claims previously rejected for invalid NDCs. The earliest possible rejection for this issue would have occurred on a claim with a March 15, 2017, date of service (DOS). Claims may continue to reject and will not be adjusted if the submitted codes on claims remain non-compliant.
Summary of change and compliant submission requirements:
Prior to this change, BCBSIL was validating all NDCs submitted on claims. BCBSIL has modified our process to align with HFS. On 837I claim submissions, BCBSIL will only validate NDCs that are present and valid based on the Healthcare Common Procedure Coding System (HCPCS) billed on the claim line. This same process will be followed to validate 837P claim lines if a given procedure code on the claim line requires an NDC per HFS guidance. If HFS requires the NDC for the procedure code, the NDC will be evaluated accordingly. The NDC will be evaluated for correct formatting of the 11-digit NDC number. The MediSpan® database comparison to obsolete status will be removed and BCBSIL will allow the claim to enter into the claim adjudication system.
BCBSIL validates NDCs using MediSpan®. Providers should ensure NDCs used in billing processes are validated against a similar pharmacy database and the NDC is valid on the DOS.
What You Need to Do
- Submit any claim previously accidentally rejected for invalid NDCs through the Availity® Provider Portal or your preferred vendor portal. This should not be marked as a corrected claim. For claims that are past the BCBSIL timely filing limits, the claim will deny for timely filing. Please disregard this denial. We need to capture the claim in our system to waive the timely filing requirement.
- BCBSIL will run reporting to identify claims that previously rejected for invalid NDCs in error that tie to claims that are now denying for timely filing in the system. This will be done monthly for a period of three months beginning on Sept. 1, 2019 to November 30, 2019.
- We will then adjust the claims that were previously rejected in error for invalid NDCs within 30 days and send a report of all adjusted claims to impacted providers at the end of each month through November 2019.
Availity is a trademark of Availity, LLC, a separate company that operates a health information network to provide electronic information exchange services to medical professionals. Availity provides administrative services to BCBSIL. Medi-Span is a trademark of the Health division of Wolters Kluwer, an independent third party vendor that is a leading global provider of information and point of care solutions for the healthcare industry. BCBSIL makes no endorsement, representations or warranties regarding any products or services provided by third party vendors such as Availity or Wolters Kluwer. If you have any questions about the products or services provided by such vendors, you should contact the vendor(s) directly.
The material presented here is for informational/educational purposes only, is not intended to be medical advice or a definitive source for coding claims and is not a substitute for the independent medical judgment of a physician or other health care provider. Health care providers are encouraged to exercise their own independent medical judgment based upon their evaluation of their patients’ conditions and all available information, and to submit claims using the most appropriate code(s) based upon the medical record documentation and coding guidelines and reference materials. The fact that a service or treatment is described in this material is not a guarantee that the service or treatment is a covered benefit and members should refer to their certificate of coverage for more details, including benefits, limitations and exclusions. Regardless of benefits, the final decision about any service or treatment is between the member and their health care provider.