Bcbs covering td-dmsa…. ndc code expired
Just wanted everyone to know that I have been on the phone with BCBSof AL for 2 days trying to figure out why they aren’t covering TD-DMSA for us. We finally got to the bottom of it and it’s notsomehting you would expect. I asked the CSR to log into the pharmacysite to see what the rejection code was for the DMSA. She said thatit says invalid NDC code and that I needed to have Wellness callthem for the new code.
I told Wellness and they called. Turns out that the NDC code hadchanged over a year ago and that the old code was invalid. No oneknew or got a warning or heads up about it. So if you are using TD-DMSA and insurance is not covering it then ask your pharmacy to re-run all the claims under the NDC code 49452262004. That is the newcode. Apparantly TONS of pharmacies did not get the heads up on theNDC code change and see if your insurance covers it.
So it’s not that BCBS won’t cover it but that the pharmacy may beusing an expired NDC code to file it.
This post tagged as: dmsa
Lurlene Mayben said,
Wrote on March 24, 2007 @ 1:55 pm
I just wanted to say thanks for sharing this info, as Ihave BCBS of Illinois. We use TD-DMSA from Lee Silsby and they onlycover $30.00 of the $120.00 it cost for the month! I never thoughtof calling them as you had.
May I ask…does your pharmacy directly submit claims to yourBCBS..or do you pay your pharmacy, get the bill with the coding andthen submit your own claim? That is how we do it, and I am assumingthat the code you referrenced below is the code that the pharmacyneeds to put on their receipt page?
Shane Dearmond said,
Wrote on March 26, 2007 @ 2:03 pm
Our drug plan is called point of sale so we have to pay the entireprice up front and file a claim to get the 80% back. However allpharmacies run our scripts through the internet system they havehooked up with BCBS. The reason is b/c they usually have a contractwith BCBS and can not charge you over the “allowed amount” that theyand BCBS have agreed upon.
Wellness got a rejection code so they told me it wasn’t covered andthat I would have to file a medical drug claim in order to hopefullyget some of it covered. In other words it didn’t have anauthorization code when they ran it through so that meant I wouldhave to file the claim with the doctors diagnosis code, the NDCcode, and the drug information.
When they re ran it with the correct NDC code it gave them anauthorization code so all I have to do now is file the claim withthe authorization code they gave me and I get my 80% back.
I bet if you ask Lee Sibly to use the NDC code below that it willwork for you and you’ll get an authorization code with no problem.If they have any questions about the MDC code tell them to callBCBS’s pharmacy line and to verify the code. It’s the most updatedcode to be filed for TD-DMSA and it’s several years old.
Wellness has never received an authorization code from BCBS of ALwhen running TD-DMSA. They will have to go through their system andre-run all patients calims to see if theirs works like ours did.Hopefully it’s not too late for some people b/c most BCBS plans havea timely filing period of only 1 year. Anything over 1 year oldwon’t be applicable for re-filing.