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

Originally published December 29, 2020
Updated January 2, 2021

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 as specified in an earlier News article titled “COVID-19 Vaccine Administration: Preparing to Electronically Submit Pharmacy Claims”.

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 two vaccine manufacturers: Pfizer-BioNTech and Moderna. As other vaccine manufacturers are approved by the FDA, additional billing instructions will be issued.

  • DHCS will reimburse the associated COVID-19 vaccine administration fee at the Medicare allowable rate for all claim types, including pharmacy.

    • When billed appropriately, providers will be reimbursed $16.94 for the first dose and $28.39 for the second dose (regardless of manufacturer).

    • Claims are subject to all other applicable billing and program requirements.

    • Pharmacy providers will not be reimbursed for the vaccine cost or a dispensing fee for a federally-provided vaccine.

  • 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.

    • Until further system changes are implemented (anticipated to be live on Sunday, January 3, 2021), dose 2 administration will also reimburse at the dose 1 rate.

    • Medi-Cal will automatically reprocess, via Erroneous Payment Correction (EPC), any pharmacy claims for dose 2 administration that are reimbursed at the dose 1 rate.

  • When billing electronically, use the applicable Submission Clarification Code (SCC) 2 (Other Override) to indicate that the first dose of a two-dose vaccine is being administered and billed for or SCC 6 (Starter Dose) to indicate that the final dose of a two-dose vaccine is being administered and billed for.

  • All other pharmacy policy billing requirements remain in effect. This includes adherence to the updated NCPDP Payer Sheet V5.7, and use of the specified NDCs and key NCPDP D.0 submission details included in the COVID-19 Vaccine Administration: Preparing to Electronically Submit Pharmacy Claims article.

  • 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.
  • Pharmacy providers are reminded not to use the following 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)

Lastly, providers planning to submit claims via RTIP, NCPDP 1.2, or 30-1 should continue to hold their claims until further notice. 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. Only pharmacy providers submitting real-time transactions using NCPDP Standard D.0, may submit claims at this time.