Claims and Billing
Filing claims can be fast and easy for AmeriHealth Caritas New Hampshire providers. Here you will find the tools and resources you need to help manage your submission of claims and receipt of payments.
What would you like to do?
Submit claims through electronic data interchange (EDI) for faster, more efficient claims processing and payment.
Submit claims electronically.
AmeriHealth Caritas New Hampshire's EDI payer ID number is 87716.
Send paper claims to:
AmeriHealth Caritas New Hampshire
Attn: Claims Processing Department
P.O. Box 7387
London, KY 40742-7387
Go to NaviNet or call Provider Services at 1‑888‑599‑1479.
If you need to request a change to a decision regarding a claim, please submit your request in writing with the Provider Appeal Form to:
AmeriHealth Caritas New Hampshire
Attn: Claim Appeals
P.O. Box 7388
London, KY 40742-7388
Claims resources
National Drug Code (NDC) billing information
Section 1927 of the Social Security Act (42 USC 1392r-8), as amended by the Patient Protection and Affordable Care Act (PPACA), permits only drugs from manufacturers (or labelers) who participate in the Medicaid Drug Rebate Program to be compensable by the Medicaid program. This includes drugs dispensed to AmeriHealth Caritas New Hampshire members.
This is your resource for information about these revisions and what you need to do as a provider.
- What is or is not included?
- How do I bill?
- How can I determine which drugs are included in the Medicaid Rebate Program?
- What is the 5-4-2 format for NDC numbers?
- What are the differences between medical and pharmacy billing?
- I need help converting J-code units to NDC. Do you have a resource?
What is or is not included?
- Any drug product, including vaccines for adults, brand name or generic, legend or non-legend, sold or distributed by a drug manufacturer (or labeler) who participates in the Medicaid Drug Rebate Program.
- Excluded from this requirement are drugs dispensed during a hospital inpatient stay and drugs dispensed under the 340B program.
How do I bill?
All claims for outpatient medications must include the National Drug Code (NDC), NDC unit qualifier, and NDC units in addition to the HCPCS codes and HCPCS quantity. This information is required to be collected on all outpatient drug claims in order for the Department of Health and Human Services to bill manufacturers for federal rebates as permitted by the Patient Protection and Affordable Care Act (PPACA).
All claims for outpatient drugs will be validated for the presence of a(n):
- Valid NDC.
- NDC that corresponds to the billed HCPCS.
- Accurate unit of measure for the NDC billed (F2, GR, ML, UN).
- NDC quantity within appropriate FDA minimum and maximum levels.
Claims not passing all of these validation criteria will be denied.
How can I determine which drugs are included in the Medicaid Rebate Program?
The Medicaid website has detailed Medicaid Drug Rebate Program data.
What is the 5-4-2 format for NDC numbers?
All drug products have an 11-digit NDC. Some of the drug manufacturers do not follow the 5-4-2 format. Regardless, if there is a missing digit in the 5-4-2 format, a zero must be added to the beginning of one of the three number sections, whichever section is deficient, in order to bring the number into 5-4-2 claim-submitting compliance. For example:
| Sample package NDC numbers | Where to add the zero |
|---|---|
| xxxx-xxxx-xx (4-4-2) | 0xxxx-xxxx-xx (5-4-2) |
| xxxxx-xxx-xx (5-3-2) | xxxxx-0xxx-xx (5-4-2) |
| xxxxx-xxxx-x (5-4-1) | xxxxx-xxxx-0x (5-4-2) |
What are the differences between medical and pharmacy billing?
Below are the primary differences between medical and pharmacy billing.
Medical claims
- Usually billed in mg.*
- One J-code represents multiple NDCs.
Pharmacy claims
- Usually billed in ml.*
- The NDC is highly specific and should match the vial administered to the member.
- The NDC must be in the appropriate 5-4-2 format to match our validation file. Refer to the 5-4-2 format explanation above.
*Therefore, the quantity billed and unit of measure qualifier will rarely match between the HCPC (J-code) and NDC. See the commonly billed J-codes (PDF) to NDC billing cross-reference guide for more information.
I need help converting J-code units to NDC. Do you have a resource?
We have created a commonly billed J-codes user guide (PDF).
Once you have identified the number of J-code units you will bill, simply take these units, divide by the conversion factor —denoted as "CF" — and this will provide the appropriate number of NDC units to bill. The proper NDC unit qualifier has also been listed to ensure that this is properly selected. Let's look at a few examples below:
Example #1 pegfilgrastim
- J2505 = 6mg.
- Each syringe administered equals one J-code unit.
- Available as a 6mg/0.6mL syringe.
- The conversion factor is 1.66 so the NDC quantity is 1/1.66 = 0.6.
- The unit qualifier is "mL."
For illustrative purposes only.
Example #2 trastuzumab
- J9355 = 10mg.
- Each vial contains 440mg or 44 J-code units.
- The conversion factor is 44 so the NDC quantity is 44/44 = 1.
- Even though it is an MDV, it is listed as "Each" which is reported with the unit qualifier "UN" for unit.
For illustrative purposes only.