The following educational information is provided to facilitate timely and accurate claim filing for reduction of billing errors, rework of claims and prompt payment of home infusion therapy services and provider office injectables.
Payment for a charge for services by a non-institutional healthcare provider for which a claim is submitted to TRICARE, shall be equal to an amount, determined to be appropriate, to the extent practicable, in accordance with the same reimbursement rules as apply to payments for similar services under the Social Security Act.
The TRICARE benefit for home infusion service is robust:
Because TRICARE is mandated by law, to the extent practicable, to pay like Medicare, Medicare’s reimbursement methodology for home infusion drugs delivered through DME has been adopted as the TRICARE Maximum Allowable Charge, reflective of the revisions made by the 21st Century Cures Act.
Network agreements may impose certain negotiated rates or other reductions to this methodology in accordance with the terms of the agreement.
Recurring billing errors
Guidelines for timely and accurate claims resolution and payment
A. NDC field: Each NDC must be reported as an 11-digit code unique to the manufacturer of the specific drug or product administered to the patient, using a 5-4-2 format (i.e., 5 digits, followed by 4 digits, followed by 2 digits) 99999999999.
B. NDC units/quantity field: The quantity of each submitted NDC must be a numeric value greater than zero. In most cases, the NDC quantity will be different from the HCPCS billed units. To determine the correct NDC quantity, refer to the data column titled CF (conversion factor) on the Noridian Crosswalk Table. This table is updated monthly by CMS.
Identify your "J" or "S" code and correlating NDC# for your combination record, divide the number of billed HCPCS units by the CF; and enter the resulting number as the NDC Quantity.
Whenever a miscellaneous "J" or "S" code is used, the CF is NOT valid. In these cases, your entry of the NDC Quantity is the sole source of quantity to be priced based on the ASP.
"J" or "S" HCPCS Quantities must always be stated in "whole" numbers. NDC quantities can be stated in up to three places to the right of the decimal. When pricing, the NDC Quantity is “rounded” to the nearest “whole” number.
C. NDC measurement (package/unit Indicator) field: The unit of measurement for each NDC must be submitted. Noridian Crosswalk Table assumes the conversion of units NOT packages. If using the conversion factor on the Noridian Crosswalk Table, the unit of measurement should always be submitted as "units". (UN, ML, or GR for electronic HIPAA 837 and "U" for paper CMS-1500 claims).
If you are one of the many providers enjoying the benefits of electronic claim filing, the following data elements should be used to submit the NDC information in the HIPAA-standard ASC X12 837 claims format:
When filing claims for home infusion medications:
The following information is provided to facilitate timely and accurate claim filing for the prompt payment of provider office injectables.
Per TRICARE, claims that include drugs that are administered other than oral method will be priced from the Medicare average sale price list. Drugs that do not appear on this list will be priced at the lesser of billed charges or 95% of the Average Wholesale Price (AWP). TRICARE requires the use of appropriate CPT/HCPC codes and the specific NDC number for pricing using 95% of the AWP.
Medicare Part B average sales price
Average wholesale price
IIS: NDC lookup crosswalk
Providers must choose their own method of obtaining the appropriate pricing for the drug by NDC. Each NDC must be reported as an 11-digit code unique to the manufacturer of the specific drug or product administered to the beneficiary, using a 5-4-2 format (i.e., 5 digits, followed by 4 digits, followed by 2 digits: 99999-9999-99). Some NDCs may be in a 10-digit format. If the NDC is not submitted in the correct format, the claim will be denied.
The quantity of each NDC must be a numeric value greater than zero. In most cases, the NDC quantity will be different from the HCPCS billed units.
The unit of measurement for each NDC must be submitted:
UN = unit
ML = milliliter
ME = milligram
GR = gram
F2 = international unit
Before considering using an unlisted or NOC procedure code, you should determine if there is another more specific code that could be indicated to describe the procedure or service being provided. If there is not a more specific code available, you are required to submit the appropriate documentation to justify the use of the unlisted procedure code and to describe the procedure or service rendered.
The following data elements should be used to submit the NDC information in the HIPAA-standard ASC X12N 837 electronic claims format.
Loop 2400
SV101 CPT/HCPCS code
SV104 CPT/HCPCS units
Loop 2410
LIN03 NDC (11-digit format)
CPT04 NDC quantity
CPT05-1 NDC unit or basis for measurement code
If you are billing for injectables, please be aware that electronic billing does accommodate two digits behind the decimal point for a more refined calculation of the dosage.
If you bill on paper using the CMS-1500 form, please use the shaded area of Fields 24A-24G to report the NDC information in the following order: qualifier, NDC code, one space, unit/basis of measurement qualifier, quantity. The number of digits for the quantity is limited to eight digits before the decimal point and two digits after the decimal. If entering a whole number, there is no need for the decimal and please do not use commas.
Providers are required to indicate the correct dosage value in the NDC drug quantity field on the claim form. In some cases, the drug value may not be a whole number. If this is the case, fractional or decimal units are appropriate to bill.