Update to Claim Submission for Drugs with Large Values

Effective April 26, 2020, NCTracks will be able to accept and process claims with drug costs of $1 million or more per unit.

Currently, the NCTracks system does not support storing drug prices of $1 million per unit or greater and therefore is unable to pay claims for drugs with values of $1 million or more. However, effective April 26, 2020, the NCTracks system will be able to store these drug prices, allowing NCTracks to pay claims for these drugs.

While the National Council for Prescription Drug Programs (NCPDP) D.0 pharmacy claim format is still unable to support values of one million more in the Gross Amount Due and Usual and Customary Charge fields, NCTracks is implementing a work around to process drugs of these prices.

The National Council for Prescription Drug Programs (NCPDP) D.0 pharmacy claim format does not support values of ‘$1,000,000’ or more in the Gross Amount Due and Usual and Customary Charge fields. Therefore, these fields cannot represent the accurate amount for a drug which costs $1 million or more per unit.

Although the NCPDP limitation will still exist, providers should populate the Gross Amount Due and Usual and Customary Charge fields with all 9s (999,999.99) when billing a drug that costs $1 million or more per unit.  This will alert NCTracks to not consider the Gross Amount Due and the Usual and Customary Charge when determining the claim reimbursement amount. NC Tracks will then pay the claim electronically based on other Lesser of Logic components.

Two new edits will exist if a calculated claim line amount exceeds $9,999,999.99. The new edits will deny at the claim line and post the following new Explanation of Benefits (EOB) codes:

Pharmacy claims:

EOB 01933, INGREDIENT CALCULATED ALLOWED AMOUNT EXCEEDS LIMIT OF $9,999,999.99

Medical claims:

EOB 01934, INGREDIENT CALCULATED AMOUNT EXCEEDS LIMIT OF $9,999,999.99: when the result of the selected drug rate multiplied by the billed units exceeds $9,999,999.99, which is the highest number that can be stored in the Line Calculated Allowed Amount.