DATE(S) OF SERVICE:
Dates: In the bottom, white half of the claim line, enter the begin (“From”) and
end (“To”) dates of service in MM DD YY format. If a service was provided on
one day only, enter the same date twice.
Physician Administered Drugs: Beginning January 1, 2008, an NDC is required in
this field to bill for physician administered drugs.
In the top, shaded half of the claim line, enter qualifier N4 followed by the drug’s
11-digit NDC without any dashes, hyphens or other punctuation. The first, second
and third sections of the NDC (separated by hyphens on the container label) must
contain 5, 4 and 2 digits, respectively, when entered on the claim form.
To facilitate this, you must add leading zeros to one or more sections of the NDC
if the container label does not display:
· 5 digits in the first section of the NDC
· 4 digits in the second section of the NDC
· 2 digits in the third section of the NDC
For example, using the 5-4-2 model described above:
· 34-73-1 on the container label is expressed as 00034007301 on the claim
· 654-3773-22 on the container label is expressed as 00654377322 on the claim
· 1645-222-65 on the container label is expressed as 16457022265 on the claim
· 12345-6-7 on the container label is expressed as 12345000607 on the claim
· 86541-4885-77 on the container label is expressed as 86541488577 on the claim
For multi-ingredient compounds, list each component separately, on its own claim
line with the 11-digit NDC is this field.
For more information and examples on billing physician administered drugs, see the
NDC Billing Reference on First Health Services’ website.
