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COVID-19 Billing Guidelines For Both Network and Non-Par Providers

Non-participating and participating providers and pharmacists can follow the same instructions when billing COVID 19 vaccines. This includes physicians and physician extenders, including those practicing in a County Health Department, Federally Qualified Health Center or Rural Health Clinic.

Billing instructions for both network and non-par providers can be found online:

• Sunshine Health: Provider Billing Manual (PDF) on Page 3
• Staywell Health Plan: Download the guidelines on the Claims Page. Click on “837 Professional FFS Claims 5010v Guide” for providers or "2015 837 Institutional FFS Claims 5010v Guide" for hospitals or providers that bill on a UB04. Guidance is on Pages 9 and 10.
• Children's Medical Services Health Plan: Download the guidelines on the Claims Page. Click on “837 Professional FFS Claims 5010v Guide” for providers or “2015 837 Institutional FFS Claims 5010v Guide” for hospitals or providers that bill on a UB04. Guidance is on Pages 9 and 10.

Similar to other COVID-19 services, the vaccines are offered at no cost to your patients. In addition:

• Providers should bill Staywell using Plan Payer ID 14163
• Providers should bill Sunshine Health using Plan Payer ID 68069
• Providers should bill CMS Health Plan using Plan Payer ID 14163
• No prescription or prior authorization is needed for all provider types, regardless of network status

As your partners in healthcare, we also created a comprehensive COVID-19 vaccine page to provide updates on billing, share tips to effectively set expectations with your patients and address questions common vaccine questions.

See additional pharmacy guidance below.

• Submit ‘MA’ in the Professional Service Code field (44Ø-E5) of the DUR/PPS Segment along with a positive incentive fee amount in the Incentive Amount Submitted field (438-E3) of the Pricing Segment when administering vaccines.
• Submit the appropriate Quantity (e.g., 0.5 ml) and Days Supply of “1”. Inappropriate Quantities or Days Supply may cause the claim to reject.
• If the claim initially rejects with the message “Prescriber Type 1 NPI Required” when submitted using the pharmacy NPI as the Prescriber ID (NCPDP Field 411- DB), resubmit with submission clarification code (SCC) 42. Please contact the CVS Caremark Pharmacy Help Desk for any additional questions related to claims processing.

Field #	NCPDP Segment and Field Name	Required Vaccine Administration Information for Processing
44Ø-E5	DUR/PPS Segment Professional Service Code	MA (Medication Administration)
4Ø9-D9	Pricing Segment Ingredient Cost Submitted	≥$0.01 Submit Vaccine Cost (If government-supplied, see below)
438-E3	Pricing Segment Incentive Amount Submitted	≥$0.01 Submit Administration Fee
426-DQ	Pricing Segment Usual and Customary Charge	≥ Incentive Amount Submitted

Government-Supplied Vaccine Programs*

When submitting administration claims for a COVID-19 vaccine provided without cost through a government COVID-19 vaccine program, pharmacies must populate specific values in the following fields:

Field #	NCPDP Field Name	Required Vaccine Administration Information for Processing
4Ø9-D9	Ingredient Cost Submitted	$0.00
423-DN	Basis of Cost Determination	15 (Free product or no associated cost)

*Providers submitting claims for COVID-19 vaccine paid for by the federal government through funding authorized by the Coronavirus Aid, Relief and Economic Security (CARES) act, or paid for by any program supplying Provider with no associated cost (zero cost) COVID-19 vaccine, shall submit claims with either $0.01 in the Ingredient Cost Submitted field (NCPDP field 4Ø9-D9) or the combination of $0.00 in the Ingredient Cost Submitted field (NCPDP field 4Ø9-D9) and a value of “15” in the Basis of Cost Determination field (NCPDP field 423-DN).

Reminder: applicable reimbursement includes a comparison to the Provider’s submitted Usual and Customary Charge (426-DQ) and Gross Amount Due (430-DU), including where the vaccine has been provided to Provider with no associated cost.

Identification of Dose Being Submitted

When submitting administration claims for a COVID-19 vaccine that requires multiple doses, pharmacies must submit the following information to indicate whether they are submitting an initial/restarter dose or the final dose in the regimen.

Field #	NCPDP Field Name	Dose	Required Vaccine Administration Information for Processing
42Ø-DK	Submission Clarification Code	Initial/Restarter Dose	02
42Ø-DK	Submission Clarification Code	Final Dose	06

As an example, included is a section of a Payer Sheet for an initial dose. Only NCPDP Segments/Fields pertinent to special COVID-19 vaccine billing instructions are shown.

CLAIM Segment Segment Identification (111-AM) = “Ø7”
Field #	NCPDP Field Name	Value	Payer Usage	Payer Situation
436-E1	PRODUCT/SERVICE ID QUALIFIER	03	M	NDC

 

CLAIM Segment Segment Identification (111-AM) = “Ø7”
Field #	NCPDP Field Name	Value	Payer Usage	Payer Situation
4Ø7-D7	PRODUCT/SERVICE ID	59267100001	M	Pfizer NDC shown as example
442-E7	QUANTITY DISPENSED	0.3	R
4Ø5-D5	DAYS SUPPLY	1	R
354-NX	SUBMISSION CLARIFICATION CODE COUNT	1	R
42Ø-DK	SUBMISSION CLARIFICATION CODE	02	R	02 = Initial/Restarter Dose 06 = Final Dose

 

DUR/PPS Segment Segment Identification (111-AM) = “Ø8”
Field #	NCPDP Field Name	Value	Payer Usage	Payer Situation
473-7E	DUR / PPS Code Counter	1	R
44Ø-E5	Professional Service Code	MA	R	MA (Medication Administration)

 

Pricing Segment Segment Identification (111-AM) = “11”
Field #	NCPDP Field Name	Value	Payer Usage	Payer Situation
4Ø9-D9	INGREDIENT COST SUBMITTED	$0.01	R	Use $0.00 for free product
412-DC	DISPENSING FEE SUBMITTED	$0.01	RW
438-E3	INCENTIVE AMOUNT SUBMITTED	$16.94	R
426-DQ	USUAL AND CUSTOMARY CHARGE	$20.00	R	Use amount greater than or equal to Incentive Amount Submitted
43Ø-DU	GROSS AMOUNT DUE	$16.96	R
423-DN	Basis of Cost Determination	01	R	Use 15 for free product

Below are the current billing codes:

Code	CPT Short Descriptor	Labeler Name	Vaccine/Procedure Name
91300	SARSCOV2 VAC 30MCG/0.3ML IM	Pfizer	Pfizer-BioNTech Covid-19 Vaccine
0001A	ADM SARSCOV2 VAC 30MCG/0.3ML 1ST	Pfizer	Pfizer-BioNTech Covid-19 Vaccine Administration – First Dose
0002A	ADM SARSCOV2 VAC 30MCG/0.3ML 2ND	Pfizer	Pfizer-BioNTech Covid-19 Vaccine Administration – Second Dose
91301	SARSCOV2 VAC 100MCG/0.5ML IM	Moderna	Moderna Covid-19 Vaccine
0011A	ADM SARSCOV2 VAC 100MCG/0.5ML 1ST	Moderna	Moderna Covid-19 Vaccine Administration – First Dose
91303	SARSCOV2 VAC AD26 .5ML IM	Janssen (Johnson and Johnson)	Janssen Covid-19 Vaccine
0031A	ADM SARSCOV2 VAC AD26 .5ML	Janssen (Johnson and Johnson)	Janssen Covid-19 Vaccine Administration

Questions? Contact your Provider Relations Representative or call Provider Services at 1-844-477-8313, Monday through Friday from 8 a.m. to 8 p.m. Eastern.