COVID-19 Vaccine Administration: Preparing to Electronically Submit Pharmacy Claims

Originally published December 28, 2020
Updated on January 6, 2021

Current Guidance

This is the third article in the COVID-19 Vaccine Administration series and covers how pharmacy providers should plan to submit their claims in the coming weeks. However, pharmacy providers should continue to hold on submitting their claims to Medi-Cal at this time. Providers will be notified in a future News article when Medi-Cal is ready to intake claims for the COVID-19 vaccine administration.

As previously announced, with the recent federal approval of COVID-19 vaccines, the Department of Health Care Services (DHCS) is seeking federal approval to help support delivery of the vaccine to all Medi-Cal beneficiaries. DHCS will follow California’s COVID-19 vaccination plan, which was approved by the California Department of Public Health (CDPH). In order to receive and administer COVID-19 vaccines, all California healthcare providers will enroll in the federal COVID-19 Vaccination Program electronically through CDPH’s provider registration and enrollment system at the COVIDReadi website. Enrollment is limited at this time to providers authorized by their local health department (LHD). Others may enroll later in January as vaccine supply increases. Before enrolling, providers need to obtain their immunization information system (IIS) ID at the California Immunization Record (CAIR2) website. Once providers have been invited by their LHD and have their IIS ID, they should confirm that they meet all requirements listed in the COVIDReadi Provider Enrollment Instructions before enrolling. For further information on the state’s vaccination planning efforts please visit https://covid19.ca.gov/vaccines/.

Even though pharmacy providers are being asked to continue to hold their claims at this time, pharmacy providers are encouraged to begin administration of the vaccine in accordance with the CDPH Allocation Guidelines for COVID-19 Vaccine During Phase 1A. Providers must keep the manufacturer consistent between doses; if the first dose administered to a patient is the Pfizer-BioNTech vaccine, then the second dose administered to the same patient must also be the Pfizer-BioNTech vaccine.

Additionally, as the federal government will pay for the initial vaccines, there is no Medi-Cal provider reimbursement for the COVID-19 vaccine itself. DHCS plans to reimburse the associated COVID-19 vaccine administration fee at the Medicare allowable rate for all claim types, including pharmacy, based on the number of required doses. DHCS has requested federal approval to provide coverage of vaccine administration for Medi-Cal beneficiaries who have restricted scope coverage or who are enrolled in the Family Planning, Access, Care, and Treatment (Family PACT) program, as well as the COVID-19 Uninsured population. In addition, DHCS has sought federal approval to pay Federally Qualified Health Centers (FQHCs), Rural Health Clinics (RHCs), and Indian Health Service (IHS) – Memorandum of Agreement (MOA) 638 Clinics for the vaccine administration fee outside of their current Prospective Payment System (PPS) or All-Inclusive Rate (AIR).

Pharmacy providers should note that they will not be reimbursed for the vaccine cost or a dispensing fee for a federally-provided vaccine.

Claim submission for pharmacy providers will be allowed in three phases:

  • Phase One: Real-time electronic submission via NCPDP Standard D.0.

  • Phase Two: Real-time electronic submission via Real Time Internet Pharmacy (RTIP)

  • Phase Three: Electronic batch submission (NCPDP 1.2) or hard copy submission of the Pharmacy Claim Form (30-1)

Instructions on how to submit real-time electronic claims (RTIP or NCPDP Standard D.0) are included in this article, however, pharmacy providers should continue to hold submission until future notification. Instructions on how to properly bill using batch electronic formats (NCPDP 1.2) and hard copy submission using the Pharmacy Claim Form (30-1), are forthcoming. All other pharmacy policy billing requirements remain in effect.

Preparing to Submit Real-Time Transactions

Currently the U. S. Food and Drug Administration (FDA) has provided Emergency Use Authorization (EUA) for two vaccine manufacturers: Pfizer-BioNTech and Moderna. As other vaccine manufacturers are approved by the FDA, additional billing instructions will be issued.

As such pharmacy providers should prepare to electronically bill claims as specified below for each respective vaccine and dose:

  • Pfizer-BioNTech COVID-19 Vaccine

    • Bill using NDC 59267100001

    • Effective for dates of service on or after December 11, 2020

    • May only be administered to patients 16 years of age and older

    • Claim quantity dispensed must be submitted as 0.3 mL per administered vaccine.

    • Dose 1:

      • When billing electronically, use Submission Clarification Code (SCC) 2 (Other Override) to indicate that the first dose of a two-dose vaccine is being administered and billed

      • When billed appropriately, providers will be reimbursed $16.94 for a 0.3 mL first dose

    • Dose 2:

      • Administer no earlier than 17 days after the first dose

      • When billing electronically, use SCC 6 (Starter Dose) to indicate that the final dose of a two-dose vaccine is being administered and billed

      • When billed appropriately, providers will be reimbursed $28.39 for a 0.3 mL second dose

  • Moderna COVID-19 Vaccine

    • Bill using NDC 80777027310

    • Effective for dates of service on or after December 18, 2020

    • May only be administered to patients 18 years of age and older

    • Claim quantity dispensed must be submitted as 0.5 mL per administered vaccine

    • Dose 1:

      • When billing electronically, use Submission Clarification Code (SCC) 2 (Other Override) to indicate that the first dose of a two-dose vaccine is being administered and billed

      • When billed appropriately, providers will be reimbursed $16.94 for a 0.5 mL first dose

    • Dose 2:

      • Administer no earlier than 24 days after the first dose

      • When billing electronically, use SCC 6 (Starter Dose) to indicate that the final dose of a two-dose vaccine is being administered and billed

      • When billed appropriately, providers will be reimbursed $28.39 for a 0.5 mL second dose

Lastly, once claims can be submitted to Medi-Cal, whether billed electronically or on paper, if they do not meet the current billing instructions provided, they will be rejected or may result in an incorrect payment. This includes exclusive use of the NDCs depicted above, and adherence to the updated Medi-Cal NCPDP Payer Sheet V5.7. Notable NCPDP D.0 submission details providers should be aware of include:

  • Use of the value MA (Medication Administered) in the Professional Service Code (440-E5) field is not supported in Medi-Cal and submission of that code may result in a claim denial.

  • Use of the value “15” in the Basis of Cost Determination (423-DN) field is not supported in Medi-Cal and submission of that code may result in a claim denial. Providers are instructed to submit the value “01” instead.
  • The Quantity Dispensed (field 442-E7) should be submitted with the value that represents the quantity of drug product administered.

  • Submission Clarification Code (field 420 -DK) should be submitted with SCC code values of 2 or 6 to indicate first dose or second dose, respectively.

Additionally, pharmacy providers should not use the following Current Procedural Terminology (CPT®) codes when billing for these vaccines, as they are not reimbursed by Medi-Cal at this time:

  • 91300 (severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2] [Coronavirus diseases (COVID-19)] vaccine, mRNA-LNP, spike protein, preservative free, 30 mcg/0.3 mL dosage, diluent reconstituted, for intramuscular use)

  • 91301 (severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2] [Coronavirus diseases (COVID-19)] vaccine, mRNA-LNP, spike protein, preservative free, 100 mcg/0.5 mL dosage, for intramuscular use)

If providers bill using these CPT® codes, they may receive a Remittance Advice Details (RAD) code of 0145: This procedure is not a Medi-Cal benefit on this date of service, and are therefore reminded that it is the administration of the vaccine that is reimbursable at this time, and not the vaccine itself.

Upcoming Updates

More updates regarding when pharmacy providers may begin submitting claims and how to bill for additional vaccines will be shared as they are made available. An FAQ regarding the administration of the COVID-19 vaccines will be made available on the Medi-Cal website in the near future.

This guidance is only effective for COVID-19 vaccines purchased by the federal government. At a future date, DHCS will provide an end date to this temporary policy and instruct providers on how they should bill for the reimbursement of provider purchased COVID-19 vaccines.

Providers with questions should contact the Telephone Service Center (TSC) Help Desk at 1-800-541-5555, 8 a.m. to 5 p.m., Monday through Friday, except holidays. Border providers and Out-of-State billers billing for in-state providers, should call 1-916-636-1200.