REMINDER and SUPPORT FROM HPSJ – National Drug Codes (NDC) and Other Health Coverage (OHC)
| Date: | May 3, 2021 |
| To: | Health Plan of San Joaquin |
| From: | Health Plan of San Joaquin (HPSJ) Providers and Facilities |
| Subject: | REMINDER and SUPPORT FROM HPSJ – National Drug Codes (NDC) and Other Health Coverage (OHC) |
| Business: | Medi-Cal Managed Care |
To support you in becoming familiar with regulatory requirements and help your billing team with submission rules, we offer this distillation of two common billing situations.
National Drug Codes (NDC)
The Federal Deficit Reduction Act of 2005 (DRA) requires all state Medicaid agencies to
collect rebates from drug manufacturers for physician-administered drugs. Collection of
rebates is accomplished with the inclusion of National Drug Codes (NDCs) with each claim submitted to Health Plan of San Joaquin. Source: https://files.medical.ca.gov/pubsdoco/ndc/ndc.aspx.
Find NDC information required with submitted claims, along with the DHCS Frequently
Asked Questions (FAQs), at https://files.medi-cal.ca.gov/pubsdoco/ndc/ndc.aspx.
If you receive a claim denial from HPSJ stating that the claim is incomplete due to missing
NDC(s) –
- The letter will say “Resubmit with NDC codes and/or bill valid NDC numbers”.
- Providers can resubmit denied claims with the required National Drug Code(s).
Other Health Coverage (OHC)
Per All Plan Letter (APL) 21-002 and State law, Medi-Cal is the payer of last resort when the member has OHC. Therefore, HPSJ members with OHC must use their OHC before using their Medi-Cal benefits.
Effective April 1, 2021, HPSJ is required to make sure providers are identifying and billing
the OHC carrier as primary.
Here are some best practices and requirements for providers –
- Providers are advised to check a member’s OHC before beginning treatment.
- Unless the provider presents proof that all payment sources have been exhausted, or the provided service meets the requirement for billing Medi-Cal directly, they must not submit claims for a member whose Medi-Cal Eligibility Record indicates OHC – other than a code of A or N.
For more information on direct bill services, the Medi-Cal website has useful resources, at:
- https://files.medi-cal.ca.gov/pubsdoco/publications/masters-mtp/part2/medinonhcp.pdf
- https://files.medi-cal.ca.gov/pubsdoco/publications/masters-mtp/part2/medinoncpt.pdf
- https://files.medi-cal.ca.gov/pubsdoco/Publications/masters-MTP/Part1/otherguide.pdf
If you receive a claim denial from HPSJ due to OHC –
- The letter will say “Submit to primary insurance, resubmit with primary EOB”.
- Once the other health provider (OHP) has been billed, and they either make a payment or send a denial determination, HPSJ should be billed as the secondary carrier.
Health Plan of San Joaquin (HPSJ) values your countless contributions to the health of your patients and our community. If you have questions, please contact our Customer Service Department at 209-942-6320. Again, we are here to support you and your staff.