Date: September 3, 2021
To: Enrolled Pharmacies
Re: Additional Instructions for COVID-19 Vaccine 3rd Booster Dose
________________________________________________________________________________________________________ October 14, 2021 Addendum to September 3, 2021 Provider Notice
This provider notice pertains specifically to the additional COVID-19 vaccine dose of the Moderna or Pfizer COVID-19 vaccine given to immunocompromised individuals who may not develop the same immune response level after vaccination as others. At the time this notice was initially released the terms "additional" and "booster" vaccine doses were not differentiated. A customer may receive the additional dose at least 28 days after the customer's second vaccine dose, not eight months after the second dose as noted below. It is billed with Submission Clarification Code 07 as identified in the instructions in this notice. All other instructions remain the same.
This notice informs providers that a third booster dose of either the Moderna or Pfizer COVID-19 vaccine is now available for customers eight months after a customer's second vaccine dose. The Illinois Department of Healthcare and Family Services will reimburse Medicaid participating pharmacies an administration fee through NCPDP claim submission for all federally allocated COVID-19 vaccines.
The specific instructions below apply to Medicaid fee-for-service claims, but the Medicaid managed care plans will also reimburse these claims through NCPDP claim submission.
Effective September 9, 2021, pharmacies can begin billing claims for dates of service beginning August 12, 2021, for the third vaccine dose and administration via an electronic NCPDP claim according to the following instructions:
- Submit each vaccine with the specific approved vaccine NDC for an eligible participant
- Submit claim with a Basis of Cost Determination (423-DN) of "15" (Free product or no associated cost) with an associated Ingredient Cost Submitted (409-D9) value of $0.00.
- Submit claim with the Professional Service Code (440-E5), populated with an "MA" (Medication Administered) to identify that the product was administered.
- Quantity Dispensed (442-D7) should be submitted with the value that represents the quantity of drug product administered.
- Days Supply (405-D5) should be submitted with a value of "1".
- Vaccines must be administered according to approved labeling for appropriate ages and dosing interval.
- Submit the vaccine administration fee listed below in the Incentive Amount Submitted field (438-E3) on the same claim as the vaccine (i.e., ingredient).
NCPDP Codes and Allowed Amounts for COVID-19 Vaccine Administration
|Dose||Submission Clarification Code|
|Incentive Amount (Administration Fee 438-E3)||Ingredient Cost|
|Multi-Dose Vaccines|| || || |
|Third Dose||07||$42.14 || $0.00|
|Single-Dose Vaccines|| || || |
The payment rate for COVID-19 vaccine administration is $42.14 to administer single-dose vaccines.
- For single-dose vaccine administration claims, the Submission Clarification Code (SCC) should remain blank.
- The payment rate for a COVID-19 vaccine administration requiring a series of two or more doses is $42.14 for each dose in the series.
- For multi-dose vaccines, submit 02 (other override) for the initial dose in the SCC field.
- For the second dose, submit 06 (the previous medication was a starter dose and now additional medication is needed to continue treatment) in the SCC field.
- For the third dose, submit 07 (booster dose) in the SCC field.
- Pharmacies must enter the NPI of the prescriber in the Prescribing Practitioner (411-DB). If the prescriber is the pharmacist, the NPI of the pharmacist may be submitted. If the pharmacy is using a pharmacist NPI, the pharmacy must submit a Submission Clarification Code (SCC) of "42" and Prescription Origin Code (419-DJ) would be "5 "– Pharmacy.
Vaccine administration for the uninsured should be billed through the federal
HRSA COVID-19 Claims Reimbursement Portal.
Pharmacy providers with questions regarding fee-for-service program vaccine administration may call the Bureau of Professional and Ancillary Services at 877-782-5565. Pharmacies billing via NCPDP for HealthChoice Illinois managed care members should contact the applicable managed care plan.
Kelly Cunningham, Administrator
Division of Medical Programs