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Medication for Addiction Treatment Billing (Use Cases)

Medication for Addiction Treatment (MAT), sometimes called Medication Assisted Treatment, is an available substance use treatment method that can be provided alongside other substance use treatment services or as a standalone service. MAT is generally provided by programs that are often referred to as Opioid Treatment Programs (OTP) or Narcotic Treatment Programs (NTP). There are two parts of this treatment that are billing: the service and the medication itself. Medi-Cal requires special claim output data when billing MAT medications with National Drug Code (NDC) values. The NDC will directly correlate with a drug type and a strength. For example, a 2 mg Buprenorphine tab has a different NDC than an 8 mg Buprenorphine tab. A client’s dosage may involve administration of multiple strengths of a drug, but Medi-Cal requires that each is clearly claimed. This requires the ability to identify specific drugs which may have multiple NDC numbers, and the ability to group them on claims as well as manipulate the number of claim units reported. A claim needs to include each medication provided on a given date and follow Medi-Cal’s rule of only 1 unit reported for each.  

Use Case: Client Receives a Specific Drug, On the Same Day, Where Multiple Doses Were Provided

For multiple reasons (dosing, manufacturer, etc.) this same drug may have different NDC values that need to be reported on the same claim.

Requirements:

  • There must be one claim that contains all medications for a given date of service.
  • Each drug administered will be reported as a separate line on the claim with its associated NDC number, and Drug Quantity information.
  • The units reported on the claim, for each unique drug (NDCs may be different), must be equal to 1, which will require the claim units to be manipulated at time of claims processing. The examples provided by the state include the split of units as .33 and .67, but other examples have shown .5 and .5 where both add up to 1 unit. The values on each line do not matter with the exception that they must add up to 1 unit per drug.

Use Case: Client Receives Different Drugs, On the Same Day, Where Multiple Doses Were Provided

For multiple reasons (dosing, manufacturer, etc.) this same drug may have different NDC values that need to be reported on the same claim.

Requirements:

  • There must be one claim that contains all medications for a given date of service.
  • Each drug administered will be reported as a separate line on the claim with its associated NDC number, and Drug Quantity information.
  • The units reported on the claim, for each unique drug (NDCs may be different), must be =1, which will require the claim units to be manipulated at time of claims processing. The examples provided by the state include the split of units as .33 and .67, but other examples have shown .5 and .5 where both add up to 1 unit. The values on each line do not matter with the exception that they must add up to 1 unit per drug.

*Note: in the example below, both Buprenorphine and Naloxone are submitted on one claim record with three service lines. The total units for Buprenorphine is 1, and the total unit for Naloxone is also 1. The claim itself contains more than one unit (in this case 2 units), but does not exceed 1 unit per drug.