National Drug Code (NDC) Requirements for Accurate Claims Processing Effective 7/1/2026
All Providers
Dear Provider,
This requirement is pursuant to Section 6002 of the Deficit Reduction Act of 2005, codified at 42 USC §1396r-8, under which the New York State Department of Health has determined that Managed Care Organizations are required to ensure providers submit complete and accurate NDC information on claims for physician-administered drugs. Additional guidance is outlined in the September 2012 Medicaid Update, Volume 28, Number 10.
For date of service 7/1/2026 and after, all applicable claims must include complete and accurate NDC information. Required NDC elements include the 11-digit NDC formatted as 5-4-2, the correct NDC unit of measure (such as ML, UN, or GR), the NDC quantity reflecting the amount administered, and an NDC description that matches the product dispensed. Accurate NDC reporting allows MetroPlusHealth to correctly identify the specific drug administered and supports federally mandated reporting. Claims submitted without valid and matching Drug code and NDC information will be denied at the line level.
MetroPlusHealth appreciates your continued partnership in delivering high-quality care to our members. To support accurate and timely claims and encounter processing, the following information is provided to clarify billing requirements for HCPCS J-codes and National Drug Codes (NDCs) for physician-administered medications and to explain the basis for the corrective action request and retrospective review process outlined above.
Complete and accurate submission of Drug codes (example J-Codes) and NDC information is required to ensure reimbursement is based on the specific drug administered, to comply with state and federal reporting requirements, and to reduce claim denials, reprocessing delays, and unnecessary administrative burden. When billing for physician-administered medications, providers are required to submit the appropriate HCPCS J-code that corresponds to the drug administered, report the correct unit of measure and quantity based on the HCPCS code description, and ensure that the J-code is active for the date of service.
Common billing errors include missing or invalid NDCs, incorrect NDC formatting, mismatches between Drug code units and NDC units, and billing the package size rather than the actual amount administered. Providers are strongly encouraged to review claims prior to submission to ensure all required data elements are accurate and complete.
Providers may reference available coding resources to support compliance, including the CMS HCPCS Quarterly Update, the Palmetto GBA PDAC NDC/HCPCS Crosswalk, and the eMedNY Provider Assistance Program website at https://www.emedny.org/info/pad/.
MetroPlusHealth is committed to supporting providers throughout the billing process. Providers who have questions regarding J-code or NDC billing requirements, or who need assistance correcting a claim, should contact Provider Relations for guidance at [email protected].
We appreciate your prompt attention to this matter and your continued commitment to accurate billing and regulatory compliance.