New clinical edit for professional claims goes into effect on July 23

We value the care you provide our members and strive to reimburse you accurately and fairly for that care. Thoughtful implementation of clinical edits supports this goal, while allowing us to process your claims more efficiently.

On July 23, we’ll implement the new clinical edit detailed below, impacting professional claims only:

Spravato Reported with Inappropriate NDC Code

Products: Commercial & Medicare

We’re aligning with Centers for Medicare & Medicaid Services (CMS) HCPCS Level II Manual and the National Drug Code (NDC) directory to deny Spravato (exketamine hydrochloride) when billed with an inappropriate NDC code.

According to the NDC directory, Spravato is dispensed with a strength of 28mg/0.2ml. NDC package code* 50458-028-03 describes an 84mg kit with three blister packs at 28mg each.

Edits will apply when HCPCS code S0013, “Esketamine nasal spray, 1mg” is reported with an NDC number that doesn’t match the units ordered to be reimbursed.
Clinical examples*:

  • Will pay: A provider bills S0013 with 84 units and NDC code 50458-028-03
  • Will deny: A provider bills S0013 with 56 units and NDC code 50458-028-03

See more clinical edits for professional claims


*Note: NDC package codes can change. The current NDC code should be used.