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SC Medicaid - SCDHHSMedicaid · Billing Codes · Claims & Billing · SCHigh impact

Physician-administered Drugs (PAD) Billing Guidance

Act
immediately
Effective date
Not stated in the notice
Identified
Sep 24, 2026

Summary

SCDHHS updated its Physician-administered Drugs (PAD) billing guidance requiring all PAD claims to include a valid NDC (National Drug Code) in 5-4-2 format (11 digits total) matched to the HCPCS code. Claims without an NDC or with an invalid NDC will be rejected or subject to payment recoup. This policy applies immediately to all outpatient settings (offices, clinics, hospitals) billing South Carolina Medicaid.

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What to do

immediately · 7 steps
01Billing team must implement the following mandatory changes for all PAD claims submitted to South Carolina SCDHHS Medicaid.
02Update billing system to require NDC entry for all drug-related HCPCS codes in the 5-4-2 format (11 digits).
03Validate that the drug manufacturer participates in the federal Medicaid Drug Rebate Program before claim submission using the Drug Manufacturer Contacts listing (first 5 NDC digits identify manufacturer).
04Establish and implement a process to record and maintain NDC and quantity for all drugs administered to members.
05Configure claim submission logic to reject or flag claims missing NDC or containing invalid NDC format across all submission methods (electronic, Web Tool, CMS-1500, UB-04).
06Consequences: Claims submitted without valid NDC will be denied or previously paid amounts will be recouped through post-payment review.
07Before October 1, 2026: Verify that all applicable provider manuals have been updated in your billing reference documentation.

Original notice

Physician-administered Drugs (PAD) Billing Guidance
scdhhs.gov · Always check the source before changing claims.
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