COVID-19 Vaccine Administration: Preparing NCPDP 1.2 and Pharmacy Hard Copy Submissions

January 13, 2021

This is the ninth article in the COVID-19 Vaccine Administration series and informs pharmacy providers how to prepare billing for NCPDP 1.2 submissions using Computer Media Claims (CMC) and hard copy (Pharmacy Claim Form [30-1]) claims. Pharmacy providers will be informed when they may begin submitting claims in a future News article.

  • NCPDP 1.2 submissions using CMC:

    • 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.

    • Pharmacy providers using electronic billing methods are expected to adhere to the Medi-Cal NCPDP Payer Sheet V5.7, which has been updated to include the SCC values 2 and 6. Other notable NCPDP submission details that providers should refer to are included in the COVID-19 Vaccine Administration: Preparing to Electronically Submit Pharmacy Claims article.

    • If these instructions are not followed, pharmacy providers should anticipate claim rejection or possibly incorrect payment amounts.

  • Hard copy (Pharmacy Claim Form [30-1]) submissions:

    • Use the Fill Number field (Box 12) to indicate if the dose being administered is the initial or final dose.

      • Enter either a 0 or 00 to indicate that the initial dose is being administered and billed

      • Enter either a 1 or 01 to indicate that the final dose is being administered and billed

    • Examples are included below for reference. Note that these are merely examples, and that providers should adjust to their billing situation as appropriate:

1) Pfizer-BioNTech initial dose:

Pfizer-BioNTech initial dose

2) Pfizer-BioNTech final dose:

Pfizer-BioNTech final dose

3) Moderna initial dose:

Moderna initial dose

4) Moderna final dose:

Moderna final dose

  • Regardless of submission type, 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.

Medi-Cal requests pharmacy providers to remain aware of the below highlights as they begin submission.

  • 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.

Lastly, 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)

As of original publication of this article, providers should continue to hold submitting their NCPDP 1.2 transactions, or 30-1 claims until further notice. Only pharmacy providers submitting real-time transactions using NCPDP Standard D.0 and RTIP may submit claims at this time.

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.