PURPOSE: This rule implements the National Drug Code (NDC) requirement for all medications administered in the clinic or outpatient hospital setting. The Deficit Reduction Act of 2005 (DRA) requires states to collect rebates for certain physicianadministered drugs.

1. (1) Drug charges submitted by providers on an electronic Professional or Institutional ASC X12 837 Health Care claim transaction or manually entered on a medical or outpatient claim into the MO HealthNet Division’s (MHD) billing website eMOMED (www.emomed.com) must be billed with a valid Healthcare Common Procedure Coding System (HCPCS) procedure code and a valid NDC for all medications administered to MHD participants in the clinic or outpatient hospital setting. MHD must collect the eleven- (11-) digit NDC on all outpatient drug claims submitted to MHD from all providers for rebate purposes to receive federal financial participation. Providers can find the NDC on the medication’s packaging, and must submit the NDC in the five (5) digit – four
2. (4) digit – two (2) digit format. If the NDC does not appear in the five (5) digit – four (4) digit – two (2) digit format on the packaging, zero(s) (0) may be entered in front of the section that does not have the required number of digits. The MHD denies medical or outpatient claim lines submitted with a HCPCS procedure code without the corresponding NDC. For medical or outpatient claims correctly submitted with the appropriate HCPCS procedure code and the corresponding NDC, the system automatically generates a separate drug claim for the NDC to process as a pharmacy claim. It will appear as a separate claim on your Remittance Advice. The MHD will drop the corresponding line with the HCPCS procedure code and NDC from the medical or outpatient claim. If an NDC is not provided, the HCPCS procedure code will remain on the claim to report the denied line. All claims must be billed with the proper NDC quantities, not the HCPCS quantities. For drugs without a valid HCPCS procedure code, revenue code 0250, “General Classification: Pharmacy,” must be used with the appropriate NDC. Only drugs and items used during outpatient care in the hospital are covered. MHD does not cover takehome medications and supplies under the Hospital Program.

AUTHORITY: sections 208.201 and 660.017, RSMo 2016.* Emergency rule filed June 19, 2015, effective July 1, 2015, expired Dec. 28, 2015. Original rule filed July 1, 2015, effective Feb. 29, 2016. Amended: Filed Sept. 27, 2018, effective May 30, 2019. Amended: Filed Jan. 16, 2020, effective Aug. 30, 2020. Amended: Filed Oct. 20, 2023, effective May 30, 2024. *Original authority: 208.201, RSMo 1987, amended 2007, and 660.017, RSMo 1993, amended 1995.