Pharmacy claims are submitted with the following fields:
- 11-digit National Drug Code (NDC) in the "Product/Service ID" field (4Ø7-D7)
- ‘03’ in the “Product/Service ID Qualifier” field (436-E1)
The NDC number submitted on the claim transaction must match the NDC number on the package or container dispensed
The 11-digit NDC number is composed of three segments:
- Labeler: 5-digit code assigned by the Food and Drug Administration (FDA) and identifies the drug manufacturer
- Product: 4-digit code assigned by the drug manufacturer and identifies the specific product
- Package: 2-digit code assigned by the manufacturer and identifies the package size
The correct format for pharmacy claim submission is an 11-digit number in a 5-4-2 format. Pharmacy staff must convert any other number, such as a 10-digit number in the 4-4-2, 5-3-2, or 5-4-1 format, before submittal. To correct the NDC place a leading zero (Ø) in either the labeler code, product code, or package size code to conform to the 5-4-2 format.
Refer to the “Multi-ingredient Compounds” section of the System Requirements chapter of this manual for instructions on how to identify the NDC on a multi-ingredient compounds claim.