COVID-19 Vaccine Administration: Real-Time NCPDP D.0 Pharmacy Claims Can Be Submitted

Originally published December 29, 2020
Updated on March 3, 2021
Most recent updates are denoted with two plus signs (++)

This is the fifth article in the COVID-19 Vaccine Administration series and informs pharmacy providers that they may begin submitting real-time claims via NCPDP Standard D.0 for the COVID-19 vaccine administration.

Some highlights that Medi-Cal wishes pharmacy providers to remain aware of as they begin submission are outlined below. In addition, clarification on system changes, reimbursement, and timelines has been added.

  • ++The Food and Drug Administration (FDA) has provided Emergency Use Authorization (EUA) for the following vaccine manufacturers:

  • As other vaccine manufacturers are approved by the FDA, additional billing instructions will be issued. Providers should refer to the COVID-19 Medi-Cal Response page for specific billing information for approved vaccines.

  • System and operational changes are required to enable successful claims adjudication.

    • The system changes for real-time NCPDP D.0 pharmacy claims submission are live in production as of Tuesday, December 29, 2020.

    • These changes enable reimbursement for the administration of dose 1 at the Medicare allowable rate of $16.94.

    • ++Further system changes were implemented on Sunday, January 3, 2021, after the original publication of this article, to allow dose 2 administration to reimburse at the Medicare allowable rate of $28.39.

    • ++Prior to these January 3, 2021, system changes, claims for dose 2 administration will have reimbursed at the dose 1 rate. Medi-Cal will automatically reprocess, via Erroneous Payment Correction (EPC), any pharmacy claims for dose 2 administration that were submitted between December 29, 2020, and January 2, 2021 and reimbursed at the dose 1 rate.

++In the original publication of this article, providers planning to submit claims via RTIP, NCPDP 1.2, or 30-1 were instructed to continue to hold their claims until further notice. As of January 19, 2021, all pharmacy claim submission types can be submitted to Medi-Cal:

++For the most current direction regarding whether or not claims should be submitted, and what behavior to expect when submitting, providers should refer to the “Pharmacy Claim Submissions” and “Medical and Outpatient Claim Submissions” tables on the COVID-19 Medi-Cal Response page.