KMAP BULLETIN: Reminder - NDC Billing Compliance

Date: 03/25/22

KMAP GENERAL BULLETIN 22049 (PDF)

The following bulletin is a reminder regarding National Drug Code (NDC) billing compliance. The example below shows a process for dispensing and billing Medicaid Pharmacy Claims that is incorrect.

Example:

Provider dispenses two (2) different pack sizes of Quilivant XR (120mL and 150ml bottles). However, the claim is billed under a single NDC for the total quantity dispensed (270mL).

Dispensing separate NDCs and subsequently billing under a single NDC is incorrect as it is a misrepresentation of services provided. The NDC and quantity billed must reflect the actual NDC and quantity dispensed. If not, the claim violates the Kansas Medical Assistance Program (KMAP) Pharmacy Provider Agreement.

Corresponding KMAP Pharmacy Provider Agreement billing requirements with the location of their published version:

Field 10: NDC

Enter the 11-digit NDC number assigned to the product dispensed (the last two digits of the NDC number are indicative of package size). It is critical that each claim reflects the NDC that appears on the drug package being dispensed. More information can be found here.

Pharmacy Provider Agreement: Terms and Requirements

9. Claims for Services Rendered

The provider agrees to be fully liable for the truth, accuracy and completeness of all claims submitted electronically or on hard copy to KMAP for payment. The provider agrees that the services listed on all claims are medically necessary for the health of the patient and are personally furnished by the provider or by the provider’s employee under the provider’s personal direction, the charges for such services are just, unpaid, and actually due according to federal and state statutes and regulations and Program policy, as announced in KMAP Provider Manuals and Bulletins and are not in excess of regular fees; the information provided on the claim is true, accurate and complete; and the words “on file” or “signature on file” when placed on the KMAP claim refers to the provider’s signature on this document available here.

Repeated incidents or refusal to correct claims may potentially be considered a violation of the Kansas Medicaid Fraud Control Act, warranting notification to the Medicaid Fraud Control Unit (MFCU). Claims may be recouped.