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Tricare refunds due to invalid NDC

jolenm

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Someone familiar with Tricare billing: Please Help!

A few months ago, our practice began receiving multiple Tricare refund requests due to "the recommended drug/vaccine dosage for the National Drug Code (NDC) units from the manufacturer has been exceeded."

The claims listed were from 2013-2016 and totaled thousands of dollars. I was taught to report the NDC#'s as 5-4-2 format and each vaccine = 1 unit. Our software doesn't support this so I have to manually enter these claims directly into MyTricare.com. I've contacted Tricare by phone and letter, but they only direct me to their online guidelines which appear to validate what myself, and the person before me, billed. When I called for help, I was told to refer to the FDA's website because Tricare doesn't have a list of vaccines and how they should be reported.

We have no choice but to refund this money, but I want to know what I'm doing wrong so this doesn't happen again in another 3 years. Tricare is the only insurance that claims we are overbilling.

Thank you in advance to anyone who can help explain this to me.
 

HangarPilot

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We bill TriCare for vaccines regularly and have not had an issue. Our software does support NDCs and we enter them similar to you ... 1 unit and adding a place-holder 0 to the first or second group as appropriate to make the NDC 11 digits 49281-400-88 becomes 49281040088, 0005-1971-01 becomes 00005197101 (no dashes).

Are you reporting the NDC from the vial (not the box)? You cannot use the NDC number on the box. For example, Tdap(Adacel) from Sanofi comes in a box of five pre-filled syringes with the NDC 49281-400-15 printed on it - but each syringe has the NDC 49281-400-88. If you report the NDC from the box you are saying you gave the patient the entire box (5 doses) of the vaccine.

What I find odd though is that if we make a mistake with an NDC, Tricare denies that item immediately. I've never seen them pay it and then come back for it. And the wording is odd ... it's not saying "NDC Invalid or missing" which is our typical denial. It says the dose is exceeded. If you're using the NDC from the box that might explain the wording. Are you having the issue with all vaccines or only certain ones?
 

cighade

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I had the same issue. The problem is the unit of measure - most vaccines are 0.5ML with the exception of Rotarix(90681) which is 1ML. In my case I was billing 1ML for all vaccines because I thought they only considered 1 unit.


Cynthia
 
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