Claims with pharmacy revenue codes (025x and 063x) require entry of both a National Drug Code (NDC) and a Healthcare Common Procedure Coding System (HCPCS) code. Additionally, providers must use Centers for Medicare and Medicaid (CMS) guidance and industry standards to associate the correct NDC to its related HCPCS code. NC Medicaid published information in March 2022 related to claims for Revenue Codes 025x and 063x. Please see previous communication Pharmacy Billing Reminder for Revenue Codes 025x and 063x.
Due to a recent audit finding, NC Medicaid is requiring Standard Plans and NC Medicaid Direct to reprocess previously paid claims with revenue code 025x and 063x, which do not have a valid NDC and/or HCPCS code.
Standard Plans will reprocess paid outpatient claims submitted with service dates July 1, 2021, and later.
- Standard Plans will communicate with the providers impacted by this reprocessing effort.
- The communication will include the request for resubmission of complete claims (i.e., including the NDC and HCPCS on the claim) and the timeline for this reprocessing activity.
- Providers will have an opportunity to resubmit these claims and timely filing requirements will be waived for these resubmitted claims. Providers should expect notification from Standard Plans by Nov. 20, 2023.
Medicaid Direct will reprocess claims submitted with service dates Jan. 1, 2020, and later.
- Medicaid Direct will communicate with providers impacted by this reprocessing effort.
- The communication will include the timeline for this reprocessing activity.
- After the reprocessing effort is completed, providers can resubmit these claims, with appropriate HCPCS and NDC included, for full payment.
- Timely filing requirements will be waived.
- Providers should expect notification from Medicaid Direct by Nov. 18, 2023.
NCTracks Call Center: 800-688-6696