Procedure for 340B Drug Claim Submissions

The North Carolina Division of Health Benefits (DHB) would like to reiterate the 340B provider and claim submission requirements for both the outpatient pharmacy and Physician’s Drug Program (PDP).  Providers are required to comply with all aspects of their respective clinical coverage policy to submit 340B claims for reimbursement.

Please note that Clinical Coverage Policy No. 9 was updated on July 15, 2019.  Prior to this update the policy allowed for submission of POS claims with an ‘8’ in the basis of cost determination field (NCPDP D.0 field 423-DN) OR a ‘20’ in the submission clarification field (NCPDP D.0 field 420-DK).  The updated policy requires use of both indicators.  In addition, providers were instructed to submit both the actual purchased drug price AND the dispensing fee in the usual and customary charge field.  Per the updated policy, only the actual purchased drug price should be submitted in the usual and customary charge field.

Physician’s Drug Program (PDP) – Clinical Coverage Policy No. 1B

• The PDP reimburses for drugs billed to Medicaid and NCHC by 340B participating providers who have registered with the Office of Pharmacy Affairs (OPA) found at https://340bopais.hrsa.gov/medicaidexclusionfiles, 
  https://340bopais.hrsa.gov/coveredentitysearch.
• Providers shall indicate that a drug was purchased under a 340B purchasing agreement by appending the ‘UD’ modifier on the drug detail.
• Providers billing for a 340B drug shall bill the cost that is reflective of their acquisition cost.

Outpatient Pharmacy – Clinical Coverage Policy No. 9 (Updated July 15, 2019)

• 340B providers must be listed on the HRSA website found at http://www.hrsa.gov/opa/.
• 340B providers must submit POS claims with an ‘8’ in the basis of cost determination field (NCPDP D.0 field 423-DN) AND a ‘20’ in the submission clarification field (NCPDP D.0 field 420-DK) to indicate they are dispensing a 340B product.  This will eliminate duplicate discounts as the claims will be pulled from rebate collections.
• 340B providers must submit the actual purchased drug price in the usual and customary charge field.
• Providers who maintain two separate inventories – one for eligible 340B prescriptions and a purchased inventory for non-340B prescriptions – may not dispense a 340B program purchased drug and bill Medicaid or NC Health Choice the calculated Medicaid price for non-qualified 340B prescriptions. 
• Hemophilia drugs
  • 340B providers may submit the state upper limit established for a 340B purchased hemophilia drug.

The referenced clinical coverage policies can be found at:

Clinical Coverage Policy 1B:  https://files.nc.gov/ncdma/documents/files/1B_1.pdf

Clinical Coverage Policy 9: https://files.nc.gov/ncdma/documents/files/9_4.pdf