Apple Health (Medicaid) providers, Community Health Plan of Washington would like to clarify the guidelines for billing the administration (injection) of drugs when the drug itself was not supplied (dispensed) by the same provider.
When billing for the administration of a drug that you did not supply, please make sure to follow these guidelines to ensure appropriate billing.
- Bill the administration through the medical benefit (the provider who supplies the drug should bill the drug through the pharmacy benefit).
- Use the appropriate CPT code for the physical administration.
- Include the name of the drug in a claim line note of the administration line billed; do not include the HCPCS drug code or the NDC number.
- Do not bill for one cent (we previously had providers bill for one cent, $0.01, for informational purposes).
Including the NDC number when you are only administering the drug may cause a delay or error in processing the claim. In addition, submitting a HCPCS/NDC combination on any claim type (pharmacy and/or medical) results in calculated “drug units” on the encounter. This makes the encounter, or the line on the encounter, subject to federal rebates, which would constitute “double dipping” (double billing) for the cost of the drug.
Should you have any questions or need additional information, please contact:
- Apple Health Customer Service, 1-800-440-1561
- Integrated Managed Care (Clark or Skamania County) Customer Service, 1-866-418-1009
- See RCW 74.09.210 (1) (c) (i), http://app.leg.wa.gov/rcw/default.aspx?cite=74.09.210