The Fidelis Care Blog

Pursuant to past guidance by the New York Department of Health (NYDOH), claims submitted under the medical benefit for medications must include a valid National Drug Code (NDC). Claims that do not include an NDC, or that include an NDC that does not match the billed HCPCS code, may be denied and/or not eligible for reimbursement.

Billing Guidance Reminders

• Submit the HCPCS code that accurately reflects the drug administered.
• Report the 11-digit NDC (5-4-2 format, no spaces or hyphens) that corresponds to the actual product administered.
• Ensure the NDC matches the HCPCS code and that both align to the service documented in the medical record.
• Verify units and any required claim elements per your billing software/clearinghouse to avoid rejections.

Common Issues

• Missing NDC on a drug claim billed under the medical benefit.
• NDC does not correspond to the billed HCPCS (e.g., different medication, different strength, dosage form, or package size than the administered product).
• Incorrect NDC format (not 11 digits).

Claim Denial Details

• Denial Code: BMB
• Explanation: HCPCS-NDC does not match

Reference: NYSDOH guidance on NDC reporting for physician-administered drugs can be found here: https://www.health.ny.gov/health_care/medicaid/program/update/medup-n-o.htm

Pursuant to past guidance by the New York Department of Health (NYDOH), claims submitted under the medical benefit for medications must include a valid National Drug Code (NDC). Claims that do not include an NDC, or that include an NDC that does not match the billed HCPCS code, may be denied and/or not eligible for reimbursement.

Billing Guidance Reminders

• Submit the HCPCS code that accurately reflects the drug administered.
• Report the 11-digit NDC (5-4-2 format, no spaces or hyphens) that corresponds to the actual product administered.
• Ensure the NDC matches the HCPCS code and that both align to the service documented in the medical record.
• Verify units and any required claim elements per your billing software/clearinghouse to avoid rejections.

Common Issues

• Missing NDC on a drug claim billed under the medical benefit.
• NDC does not correspond to the billed HCPCS (e.g., different medication, different strength, dosage form, or package size than the administered product).
• Incorrect NDC format (not 11 digits).

Claim Denial Details

• Denial Code: BMB
• Explanation: HCPCS-NDC does not match

Reference: NYSDOH guidance on NDC reporting for physician-administered drugs can be found here: https://www.health.ny.gov/health_care/medicaid/program/update/medup-n-o.htm