Provider Alert! Outpatient Medical Drug Billing Requirements Reminder

Attention: All Providers

Effective Date: September 1, 2020

Providers should monitor the Texas Children’s Health Plan (TCHP) Provider Portal regularly for alerts and updates associated to the COVID-19 event.  TCHP reserves the right to update and/or change this information without prior notice due to the evolving nature of the COVID-19 event. 

Call to action: Effective September 1, 2020, TCHP will reject outpatient medical drug claims for clinician administered drugs (CADs) without the proper national drug code (NDC), healthcare common procedure coding system (HCPCS), and billing unit combination. The date of service must also be in the correct date range.  Please note this only applies to outpatient CAD claims.  

The correct combinations are listed on the Texas NDC to HCPCS Crosswalk and is intended to assist providers with accurate claims submission for Texas Medicaid. The crosswalk is updated quarterly, and can be accessed from the Texas Vendor Drug Program website. The crosswalk includes: 

• The eligible NDC for billing Texas Medicaid  
• The HCPCS code linked to the NDC 
• The relation start and end date between NDC and HCPCS. The date(s) of service must be within this range to be considered eligible for reimbursement. 
• The NDC package measurement. The crosswalk includes a “conversion factor” to assist as needed.    

How this impacts providers: Providers should ensure their staff, medical billing team partners, and others involved with medical billing are aware of the crosswalk requirements. Billing personnel should ensure they have the latest crosswalk for reference. Claims without this proper combination will be rejected.  

Next steps for providers: The Texas NDC-to-HCPCS Crosswalk is updated quarterly and can be found at www.txvendordrug.com/formulary/clinician-administered-drugs.shtml. Resources to assist with CAD billing include FAQs, Training materials, and the TMPPM Handbook can also be found on this website.  

If you have any questions, please email Provider Network Management at: providerrelations@texaschildrens.org. 

For access to all provider alerts, log into:
www.thecheckup.org or www.texaschildrenshealthplan.org/for-providers.