NCPDP releases guidance on COVID-19 vaccine billing

NCPA December 4, 2020

New information is available for pharmacies that plan to submit reimbursement claims for vaccine administration to PBMs. There’s a lot of information in the guidance on paid and rejected claim responses. The NCPDP guidance is not a mandate for PBMs, but many may implement the recommendations as published. Talk to your pharmacy management system vendor; they may have tips for simplifying the use of these codes. For general questions, email Lisa Schwartz at NCPA.

  • One-dose COVID-19 vaccine: Use the actual liquid volume (e.g., 0.5 mL) for the Quantity Dispensed, a Days Supply of “1,” Professional Service Code “MA,” and Ingredient Cost of $0.00 or $0.01 (depending on the payer).

  • Two-dose COVID-19 vaccine: Use the actual liquid volume (e.g., 0.5 mL) for the Quantity Dispensed, a Days Supply of “1,” Professional Service Code “MA,” Ingredient Cost of $0.00 or $0.01 (depending on the payer), and the appropriate SCC indicating which dose in the series as follows:

    • Initial Dose - Submission Clarification Code of 2 “Other Override” defined as, “Used when authorized by the payer in business cases not currently addressed by other SCC values,” to indicate the first dose of a two-dose vaccine is being administered.

    • Final Dose- Submission Clarification Code of 6 “Starter Dose” defined as, “The pharmacist is indicating that the previous medication was a starter dose and now additional medication is needed to continue treatment,” to indicate the final dose of a two-dose vaccine is being administered.

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