Improving Claim Submission Accuracy: Greater Transparency = Provider Engagement: A Case Study on NDC Mandates

$35 billion of drug-related revenue comes from healthcare provider offices. Health plans have established policies that require additional information, not just the HCPCS code. This additional information enables payors to differentiate between drugs that exist under the same billing codes. Recent claims analysis revealed a high degree of confusion from providers on what is required to meet NDC unit mandates. Learn how additional coding data can assist claims processing as well as the value of the implementation of better payment structures.

Improving Claim Submission Accuracy Starts with
Provider Engagement through Greater Transparency

A Case Study on NDC Mandates

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Written by:

Todd Cooperman, PharmD, MBA, R.Ph.Cristina Arnold BSN, RN
SVP, Clinical Insights and AnalyticsSVP, Sales and Market Development

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RJ Health is a drug data, application & analytics provider to the pharmacy reimbursement market, who brings scalability to specialty drug innovation. We focus on specialty drug innovation (new approvals and additional indications), as well as normalizing reimbursement for drug classifications that have market forces at-play (generics / biosimilars, rebates, and CMS policy). The company provides industry standard pricing, coding, dosing, weight, age, and diagnosis data & analyses to pharmacy, market access, claims, billing, finance, and network management clientele. RJ Health ensures transparency between manufacturer, payor, provider, pharmacies and their respective solution vendors (PBMs, Payment Integrity, Revenue Cycle, EHR, etc…) – all licensees of RJ Health data. 

Our tools and data:

Assist in understanding drug pricing and healthcare reimbursement for drug claims

Enable organizations to look up and crosswalk NDCs and HCPCS codes – J codes, C codes and other

 Assist in calculating drug dosage accurately and ensure claims are reimbursed properly based on unit requirements

Ensure claim accuracy and crosswalk drug codes

Help organizations make the best decisions for drug formularies

Combine clinical diagnosis and procedural coding matched to the right drug and dosage, as well as the most cost-efficient specialty drug price