Reminder on the use of National Drug Codes (NDC)

All providers must comply with the NJ Medicaid NDC requirements.

  1. When billing for “J” and “Q” codes, the appropriate NDC number, quantity, unit of measure and revenue code must be submitted. If this information is not submitted in the claim, NJ Medicaid requires Horizon NJ Health to deny the claim.

  2. NDC quantity must be valid. The calculated allowed amount (quantity X price) should not be more than two times the billed amount using billable (outer NDCs) wholesale acquisition cost. If the calculated amount exceeds this, NJ Medicaid requires us to deny the claim with the message “NDC quantity exceeded*.”

  3. Billable (outer NDCs) wholesale acquisition cost is required to calculate and valid NDC code in drug master for the date of service. The inner NDC is acceptable if it has the wholesale acquisition cost. It is recommended to use the outer NDC which will always have the wholesale acquisition cost.

For more information, visit Explanation of reason codes and descriptions for the NDC denial codes.
*Review example under Edit 330 on Explanation of reason codes and descriptions for the NDC denial codes.

 

Published on: August 1, 2019, 04:34 AM ET
Last updated on: August 27, 2019, 03:37 AM ET
Tikka Attach

New NDC edits codes effective September 2019

STATE
EDITS

01 Denial Codes
(Claims reviewed

by examiners)

XC Denial
Codes

(Batch process)
EOB

Codes
Short

Description
Long

Description Remark
Print

on EOB
CARC /
RARC

551 I85 I89 I63
NDC probably

obsolete for date
of service

NDC on this claim is no
longer valid for the dates

of service
Deny claim Y 16/M119

300 I82 I84 I70 Maximum dosage exceeded
Validate claims based

on the maximum daily
dosage exceeded

Deny claim Y 222/N362

215 I8A I8B I8C
NDC ? Healthcare

Common Procedure
Coding System

(HCPCS) mismatch

NDC ? HCPCS codes
combination is invalid Deny claim Y 16/M119

Existing NDC edit implemented in August 2018

STATE
EDITS

01 Denial Codes
(Claims reviewed

by examiners)

XC Denial
Codes

(Batch process)
EOB

Codes
Short

Description
Long

Description Remark
Print

on EOB
CARC /
RARC

214 I71 I41 I54
NDC Code is invalid/
no WAC price in First

Data Bank (FDB)

NDC number is invalid for
date of service or WAC price

is not available in FDB
Deny claim Y 16/M119

317 I72 I45 I55 NDC quantity is invalid
NDC quantity has invalid

metric quantity Deny claim Y 16/M119

322 I74 I50 I57
NDC unit

of measurement
is invalid

Must have a valid unit
of measure gram (GR),

milliliter (ML), units (UN),
International Units (F2)
and should be valid for

the NDC code

Deny claim Y 16/M119

330 I75 I51 I58 NDC quantity exceeded

Quantity should be valid
and calculated allowed

amount (quantity X price)
should not be more than

two times of the billed
amount

Deny claim Y 222/N362

328 I76 I52 I59
Valid revenue codes

are required for
this NDC

Outpatient drug claims are
required revenue codes
631 through 637 or 25x

Deny claim Y 16/M50

544 I77 I53 I61
NDC is in Drug
Efficacy Study

Implementation
(DESI) file

NDC is not payable and
invalid in Federal

DESI file for the date
of service

Deny claim Y 16/M119

323 NA NA I67
Warning

NDC not in
Maximum Dosage

File

Warning
NDC is not in Maximum
Daily Dosage File for the

claims date of service
Warning

Explanation of reason codes and
descriptions for the NDC denial codes

1



DOS FROM DT DOS to Dt Procedure Proc Units NDC NDC Units
Charge
Amount Paid Amount

4/18/2018 4/18/2018 J2469 5 68256079701 5 $500.00 $231.05

DOS FROM DT DOS to Dt Procedure Proc Units NDC NDC Units
Charge
Amount Paid Amount

10/24/2017 10/24/2017 J7050 1 00264180032 264180032 $25.00 $3.21

DOS
FROM DT DOS to Dt Procedure

Proc
Units NDC

NDC
Units NDC UOM

Charge
Amount

Paid
Amount

1/8/2018 1/8/2018 J1745 50 57894003001 1 ML $37,854.00 $5,710.35

EDIT ? 317

DENIAL CODE
(01 CLAIMS ? WORKED

BY EXAMINERS)
Denial Code

(Batch Process)
EOB
Code

State
Encounter
Edit Code

Short
Description

Long
Description

I72 I45 I55 317 NDC quantity is invalid NDC quantity has invalid metric quantity.

Claim example: The claim/encounter was rejected because the NDC units billed are invalid.
The provider billed the NDC code in place of the NDC units.

EDIT ? 322

DENIAL CODE
(01 CLAIMS ? WORKED

BY EXAMINERS)
Denial Code

(Batch Process)
EOB
Code

State
Encounter
Edit Code

Short
Description

Long
Description

I74 I50 I57 322 NDC unit of measurement is invalid Must have a valid UOM F2, GR, ML, UN and should be valid for the NDC code.

Claim example: The claim/encounter was rejected because the NDC UOM was billed as ML, but it should have been billed as UN.

NDC edit implemented August 2018 ? Examples: EDIT ? 214

DENIAL CODE
(01 CLAIMS ? WORKED

BY EXAMINERS)
Denial Code

(Batch Process)
EOB
Code

State
Encounter
Edit Code

Short Description Long Description

I71 I41 I54 214 NDC code is invalid/no WAC price in FDB
NDC number is invalid for date of service or

WAC price is not available in FDB.

Claim example: The claim/encounter was rejected because the NDC code 68256079701 is not a valid NDC code.

EDIT ? 330

DENIAL CODE
(01 CLAIMS ? WORKED

BY EXAMINERS)
Denial Code

(Batch Process)
EOB
Code

State
Encounter
Edit Code

Short
Description

Long
Description

I75 I51 I58 330 NDC quantity exceeded
Quantity should be valid and calculated allowed

amount (quantity X price) should not be more than
two times the billed amount.

Claim example: The below claim/encounter (Claim ID - 18085F959900 line 1) was rejected because (claim charge amount * 2)
is less and this should be more than total NDC price (NDC price * NDC units billed).

2



EDIT ? 328

DENIAL CODE
(01 CLAIMS ? WORKED

BY EXAMINERS)
Denial Code

(Batch Process)
EOB
Code

State
Encounter
Edit Code

Short
Description

Long
Description

I76 I52 I59 328 Valid revenue codes are required for this NDC
Outpatient drug claims use revenue

codes 631 through 637 or 25x.

Claim example: The claim/encounter was rejected because the revenue code billed on the outpatient claim was invalid.

DOS
FROM DT DOS to Dt Procedure

Proc
Units NDC

NDC
Units Charge Amount

Paid
Amount

3/22/2018 3/22/2018 J9271 200 00006302602 200 $16,000.00 $9,344.00

Claim charge amount * 2 g $16,000 * 2 = $32,000
Total NDC Price g $1,145.23 * 200 = $229,046
In this case, since the (claim charge amount * 2) is less and this should be more than total NDC price (NDC price * NDC units billed)
the provider has billed the NDC units incorrectly.
Claim example 2: The below claim/encounter (Claim ID - 18247I516300 line 1) was rejected as (claim charge amount * 2)
is less and this should be more than total NDC price (NDC price * NDC units billed).

DOS
FROM DT DOS to Dt Procedure

Proc
Units NDC

NDC
Units Charge Amount

Paid
Amount

8/30/2018 8/30/2018 J3380 300 64764030020 300 $10,800.00 $6,219.00

Claim charge amount * 2 g $10,800 * 2 = $21,600
Total NDC Price g $6,097.57 * 300 = $1,829,271
In this case, since the (claim charge amount * 2) is less and this should be more than total NDC price (NDC price * NDC units billed)the
provider has billed the NDC units incorrectly.

DOS
FROM DT DOS to Dt Procedure Proc Units Revenue code NDC NDC Units

1/29/2018 1/29/2018 J3490 4 0270 24357070106 20

EDIT ? 544

DENIAL CODE
(01 CLAIMS ? WORKED

BY EXAMINERS)
Denial Code

(Batch Process)
EOB
Code

State
Encounter
Edit Code

Short
Description

Long
Description

I77 I53 I61 544 NDC is not in DESI file NDC is not payable and invalid in Federal DESI file for the date of service.

Claim example: The above claim/encounter was rejected because the NDC billed has been classified as a less than effective (LTE)
DESI drug effective 11/18/2014, which is lesser than the DOS on the claim.

DOS
FROM DT DOS to Dt Procedure

Proc
Units

Revenue
Code NDC NDC Units

Charge
Amount

Paid
Amount

8/30/2018 8/30/2018 J3380 300 64764030020 300 $10,800.00 $6,219.00 $6,219.00

September 2019 NDC Edits 9 ? EDIT ? 300 - Maximum dosage exceeded

DENIAL CODE
(01 CLAIMS ? WORKED

BY EXAMINERS)
Denial Code

(Batch Process)
EOB
Code

State
Encounter
Edit Code

Short
Description

Long
Description

I82 I84 I70 300 Maximum dosage exceeded
NDC metric quantity reported on the claim exceeds the

Maximum Daily Dosage File for the claims date of service.

Claim example: The below claim/encounter was rejected because the NDC metric quantity reported on the claim exceeds
the Maximum Daily Dosage File for the claims date of service.

3



DOS
FROM DT DOS to Dt Procedure Proc Units Revenue Code NDC NDC Units

Charge
Amount

Paid
Amount

2/12/2018 2/12/2018 J9201 8 00002750101 39.211 $3,296.00 $103.44 $6,219.00

Dosage details for the NDC:

NDC MDD Effective Date Term Date
00002750101 20 6/9/2009 12/31/9999

EDIT ? 551

DENIAL CODE
(01 CLAIMS ? WORKED

BY EXAMINERS)
Denial Code

(Batch Process)
EOB
Code

State Encounter
Edit Code

Short
Description

Long
Description

I85 I89 I63 551 NDC probably obsolete
NDC on this claim is obsolete and is no longer

valid for the dates of service on this claim.

Claim example: The below claim/encounter was rejected because the NDC reported on the claim is obsolete for the claims date of service.

DOS
FROM DT DOS to Dt Procedure

Proc
Units

Revenue
Code NDC NDC Units

Charge
Amount

Paid
Amount

12/19/2018 12/19/2018 J0885EC 60 54868580200 1.5 $3,567.00 $3,567.00 $133.84

EDIT ? 215

DENIAL CODE
(01 CLAIMS ? WORKED

BY EXAMINERS)
Denial Code

(Batch Process)
EOB
Code

State Encounter
Edit Code

Short
Description

Long
Description

I8A I8B I8C 215 NDC ? HCPCS mismatch
NDC ? HCPCS combination does not
match the Centers for Medicare and

Medicaid (CMS) crosswalk.

Claim example: The below claim/encounter was rejected because the NDC ? HCPCS combination does not match the CMS crosswalk.

DOS
FROM DT DOS to DT Procedure

Proc
Units NDC

NDC
Units

Charge
Amount

Paid
Amount

2/16/2019 2/16/2019 J9044 (Injection, bortezomib, not otherwise specified, 0.1 mg) 35
63020004901

(VELCADE 3.5 MG VIAL) 1 $4,809.00 $1,635.20

NDC ? HCPCS crosswalk

J CODE J code Description NDC NDC Description
J9044 Injection, bortezomib, not otherwise specified, 0.1 mg 63323072110 BORTEZOMIB 3.5 MG VIAL

For the most recent NDC-HCPCS (J code) cross walk table, visit
CMS.gov/Medicare/Medicare-Fee-for-Service-Part-B-Drugs/McrPartBDrugAvgSalesPrice/2019ASPFiles.html.

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