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
