Reimbursement Guidelines
Blue Cross NC will limit reimbursement for drugs and biologicals per guidance from the FDA-approved indications and acceptable off-label indications, unless otherwise specified in a separate pharmacy policy. This helps ensure appropriate indications for use, dosing limits, and frequency of use.
Blue Cross NC will only reimburse one claim line of an administered drug or biological per day, per provider or same group practice. If multiple lines of the same drug/code are billed on the same claim or date of service and one line does not contain a JW modifier, the line(s) with an equal or lower quantity will be denied.
Drugs and biologicals with multiple administration routes must be billed with modifiers (JA, JB) to indicate route of administration.
Single Use Vial or Package
Modifier JW or JZ are required to be submitted with single use vial or package of drug or biologicals. When Modifier JW or JZ are not submitted, the drug or biological will be denied.
When there is no discarded/wasted drug or biological from a single use vial or package, Modifier JZ must be used to be eligible for reimbursement.
Discarded/wasted drug or biological from a single use vial or package are only eligible for reimbursement when submitted with Modifier JW. Reimbursement for drug or biological wastage (indicated by the Modifier JW) is limited to the units contained in the smallest single use vial or package available for purchase from the manufacturer(s). Modifier JW must be filed on a separate claim line from the administered drug or biologic to be eligible for reimbursement. Drug or biologic wastage alone is not reimbursable.
Multi-use Vial or Package
Modifier JW cannot be used to indicate drug or biological wastage for multi-use vials. Wastage for multi-use vials is not reimbursable.