Clinician-Administered Drug Claims

The manufacturer will dispute a claim in the following situations:

  • Omission of the decimal point
  • The provider rounds the quantity up to the following whole number
  • The provider does not enter the number of units administered based on the Healthcare Common Procedure Coding System (HCPCS) description and conversion factor.

 If a manufacturer disputes a claim, the HHSC rebate administrator will contact HHSC for clarification.

Common dispute reasons include:

  • The quantity administered was not reported correctly. This is most common if the HCPCS description is for more than 1.  For example, the description for HCPCS code J1885 is "Injection, ketorolac tromethamine, per 15 mg", therefore 15 mg equals 1 HCPCS unit. If 15 mg is administered, then the correct number of HCPCS units to claim is 1, not 15. Likewise, if 30 mg is administered, the number of units claimed would be 2. The number of HCPCS must then be converted to reflect the correct units for the NDC used.
  • Low reimbursement is received for the quantity of services provided or the amount claimed.
  • A missing or invalid NDC on the claim