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 for TRICARE.
TRICARE requires the use of appropriate "J" or "S" HCPCS codes and the specific NDC for pricing using ASP+6%, effective 1-1-2017. This would apply to drugs applied through Durable Medical Equipment (DME).
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.
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: