COVID-19 Vaccine Administration: Real-Time RTIP Pharmacy Claims Can Be Submitted

Originally published January 4, 2021
Updated on January 6, 2021

This is the eighth article in the COVID-19 Vaccine Administration series and informs pharmacy providers that they may begin submitting real-time claims via the Real Time Internet Pharmacy (RTIP) claim submission system for the COVID-19 vaccine administration as specified in an earlier News article titled “COVID-19 Vaccine Administration: Preparing to Electronically Submit Pharmacy Claims”.

Medi-Cal requests pharmacy providers to remain aware of the below highlights as they begin submission. 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 RTIP pharmacy claims submission are live in production as of Monday, January 4, 2021.

    • These changes enable reimbursement for the administration of dose 1 at the Medicare allowable rate of $16.94, and the administration of dose 2 at the Medicare allowable rate of $28.39.

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

  • NCPDP D.o transactions - SCC values

  • Pharmacy providers are expected to adhere to Medi-Cal’s NCDP Payer Sheet V5.7, which has been updated to include the SCC values 2 and 6. No other NCPDP D.0 transaction changes are expected at this time.

  • 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 batch electronic formats (NCPDP 1.2), or the Pharmacy Claim Form (30-1) should continue to hold their claims until further notice. Instructions on how to properly bill for both, are forthcoming. Only pharmacy providers submitting real-time transactions using NCPDP Standard D.0 or RTIP, may submit claims at this time.