Avoiding Recoupments: Why Accurate 11-Digit NDC Billing Matters

of the full 11-digit NDC billed also comes up when a pharmacy receives a notice from Humana indicating a claim (or multiple claims) are facing recoupment for billing an unlisted or invalid NDC.

These recoupment notices likely stem from claims identified by CMS through retroactive validation of Prescription Drug Event (PDE) records. The PDEs are compared to the FDA’s Comprehensive NDC SPL Data Elements (NSDE) File, an extensive database which includes NDCs, proprietary name, marketing category, application number, marketing start and end dates, billing unit of measure and more. Claims billed with an inactive or invalid NDC according to the data within the NSDE can be flagged by CMS in the PDE reviews.

When such claims are identified by CMS, they alert the plan sponsor (e.g., Humana) so the PDE can be corrected or reversed. This prompts Humana to reach out to the pharmacy to validate the claim data. Humana will send a notification to the pharmacy identifying such claim(s) by listing the member ID, date of service, prescription number and the original NDC submitted, then provide the pharmacy an opportunity to correct the NDC.

To validate the claim(s), the pharmacy has two options:

1. The pharmacy must write a corrected NDC in the space provided on the chart in the recoupment notice which reflects the actual NDC dispensed
2. The pharmacy reiterates that the original NDC billed was correct by sending a dated purchase order from the pharmacy’s supplier listing the NDC billed was shipped to the pharmacy prior to the fill date of the prescription

PAAS Tips:

• All 11-digits are important, even the last two digits which are an indicator of package size. Ensure all 11-digits match on every claim billed to avoid shortage issues during an invoice audit.
• Consider using barcode scanning technology as a method for verifying the 11-digit NDC billed matches the 11-digit NDC of the product dispensed. Systematic processes, such as barcode scanning technology, help eliminate human error and can block the claim from being finalized until the NDC is corrected.