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COVID-19 Billing Guidelines For Both Network and Non-Par Providers

Non-participating and participating providers and pharmacists can follow the same instructions when billing COVID 19 vaccines. This includes physicians and physician extenders, including those practicing in a County Health Department, Federally Qualified Health Center or Rural Health Clinic.

Billing instructions for both network and non-par providers can be found online:

  • Sunshine Health: Provider Billing Manual (PDF) on Page 3
  • Staywell Health Plan: Download the guidelines on the Claims Page. Click on “837 Professional FFS Claims 5010v Guide” for providers or “2015 837 Institutional FFS Claims 5010v Guide” for hospitals or providers that bill on a UB04. Guidance is on Pages 9 and 10.
  • Children's Medical Services Health Plan: Download the guidelines on the Claims Page. Click on “837 Professional FFS Claims 5010v Guide” for providers or “2015 837 Institutional FFS Claims 5010v Guide” for hospitals or providers that bill on a UB04. Guidance is on Pages 9 and 10.

Similar to other COVID-19 services, the vaccines are offered at no cost to your patients. In addition:

  • Providers should bill Staywell using Plan Payer ID 14163
  • Providers should bill Sunshine Health using Plan Payer ID 68069
  • Providers should bill CMS Health Plan using Plan Payer ID 14163
  • No prescription or prior authorization is needed for all provider types, regardless of network status

As your partners in healthcare, we also created a comprehensive COVID-19 vaccine page to provide updates on billing, share tips to effectively set expectations with your patients and address questions common vaccine questions.

See additional pharmacy guidance below.

  • Submit ‘MA’ in the Professional Service Code field (44Ø-E5) of the DUR/PPS Segment along with a positive incentive fee amount in the Incentive Amount Submitted field (438-E3) of the Pricing Segment when administering vaccines.
  • Submit the appropriate Quantity (e.g., 0.5 ml) and Days Supply of “1”. Inappropriate Quantities or Days Supply may cause the claim to reject.
  • If the claim initially rejects with the message “Prescriber Type 1 NPI Required” when submitted using the pharmacy NPI as the Prescriber ID (NCPDP Field 411- DB), resubmit with submission clarification code (SCC) 42. Please contact the CVS Caremark Pharmacy Help Desk for any additional questions related to claims processing.

Field #

NCPDP Segment & Field Name

Required Vaccine Administration Information for Processing

44Ø-E5

DUR/PPS Segment
Professional Service Code

MA
(Medication Administration)

4Ø9-D9

Pricing Segment
Ingredient Cost Submitted

≥$0.01
Submit Vaccine Cost
(If government-supplied, see below)

438-E3

Pricing Segment
Incentive Amount Submitted

≥$0.01
Submit Administration Fee

426-DQ

Pricing Segment
Usual and Customary Charge

≥ Incentive Amount Submitted

Government-Supplied Vaccine Programs*

When submitting administration claims for a COVID-19 vaccine provided without cost through a government COVID-19 vaccine program, pharmacies must populate specific values in the following fields:

Field #

NCPDP Field Name

Required Vaccine Administration Information for Processing

4Ø9-D9

Ingredient Cost Submitted

$0.00

423-DN

Basis of Cost Determination

15
(Free product or no associated cost)

*Providers submitting claims for COVID-19 vaccine paid for by the federal government through funding authorized by the Coronavirus Aid, Relief and Economic Security (CARES) act, or paid for by any program supplying Provider with no associated cost (zero cost) COVID-19 vaccine, shall submit claims with either $0.01 in the Ingredient Cost Submitted field (NCPDP field 4Ø9-D9) or the combination of $0.00 in the Ingredient Cost Submitted field (NCPDP field 4Ø9-D9) and a value of “15” in the Basis of Cost Determination field (NCPDP field 423-DN).

Reminder: applicable reimbursement includes a comparison to the Provider’s submitted Usual and Customary Charge (426-DQ) and Gross Amount Due (430-DU), including where the vaccine has been provided to Provider with no associated cost.

Identification of Dose Being Submitted

When submitting administration claims for a COVID-19 vaccine that requires multiple doses, pharmacies must submit the following information to indicate whether they are submitting an initial/restarter dose or the final dose in the regimen.

Field #

NCPDP Field Name

Dose

Required Vaccine Administration Information for Processing

42Ø-DK

Submission Clarification Code

Initial/Restarter Dose

02

42Ø-DK

Submission Clarification Code

Final Dose

06

As an example, included is a section of a Payer Sheet for an initial dose. Only NCPDP Segments/Fields pertinent to special COVID-19 vaccine billing instructions are shown.

CLAIM Segment
Segment Identification (111-AM) = “Ø7”

Field #

NCPDP Field Name

Value

Payer Usage

Payer Situation

436-E1

PRODUCT/SERVICE ID QUALIFIER

03

M

NDC

 

CLAIM Segment
Segment Identification (111-AM) = “Ø7”

Field #

NCPDP Field Name

Value

Payer Usage

Payer Situation

4Ø7-D7

PRODUCT/SERVICE ID

59267100001

M

Pfizer NDC shown as example

442-E7

QUANTITY DISPENSED

0.3

R

4Ø5-D5

DAYS SUPPLY

1

R

354-NX

SUBMISSION CLARIFICATION CODE COUNT

1

R

42Ø-DK

SUBMISSION CLARIFICATION CODE

02

R

02 = Initial/Restarter Dose 06 = Final Dose

 

DUR/PPS Segment
Segment Identification (111-AM) = “Ø8”

Field #

NCPDP Field Name

Value

Payer Usage

Payer Situation

473-7E

DUR / PPS Code Counter

1

R

44Ø-E5

Professional Service Code

MA

R

MA (Medication Administration)

 

Pricing Segment
Segment Identification (111-AM) = “11”

Field #

NCPDP Field Name

Value

Payer
Usage

Payer Situation

4Ø9-D9

INGREDIENT COST SUBMITTED

$0.01

R

Use $0.00 for free product

412-DC

DISPENSING FEE SUBMITTED

$0.01

RW

438-E3

INCENTIVE AMOUNT SUBMITTED

$16.94

R

426-DQ

USUAL AND CUSTOMARY CHARGE

$20.00

R

Use amount greater than or
equal to Incentive Amount Submitted

43Ø-DU

GROSS AMOUNT DUE

$16.96

R

423-DN

Basis of Cost Determination

01

R

Use 15 for free product

Below are the current billing codes:

Code

CPT Short Descriptor

Labeler Name

Vaccine/Procedure Name

91300

SARSCOV2 VAC
30MCG/0.3ML IM

Pfizer

Pfizer-BioNTech Covid-19 Vaccine

0001A

ADM SARSCOV2 VAC
30MCG/0.3ML 1ST

Pfizer 

Pfizer-BioNTech Covid-19 Vaccine
Administration – First Dose

0002A

ADM SARSCOV2 VAC
30MCG/0.3ML 2ND

Pfizer 

Pfizer-BioNTech Covid-19 Vaccine
Administration – Second Dose

91301

SARSCOV2 VAC
100MCG/0.5ML IM 

Moderna 

Moderna Covid-19 Vaccine

0011A

ADM SARSCOV2 VAC
100MCG/0.5ML 1ST 

Moderna

Moderna Covid-19 Vaccine
Administration – First Dose

91303

SARSCOV2 VAC
AD26 .5ML IM

Janssen
(Johnson & Johnson)

Janssen Covid-19 Vaccine

0031A

ADM SARSCOV2 VAC
AD26 .5ML

Janssen (Johnson & Johnson)

Janssen Covid-19 Vaccine Administration

Questions? Contact your Provider Relations Representative or call Provider Services at 1-844-477-8313, Monday through Friday from 8 a.m. to 8 p.m. Eastern.

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Y0070_WCM_64252E Last Updated On: 4/15/2021