Date: October 14, 2021
To: Enrolled Pharmacies
Re: Instructions for COVID-19 Vaccine Additional Dose and Booster Dose
________________________________________________________________________________________________________ This notice informs providers that a broader population can now receive the booster dose of the Pfizer COVID-19 vaccine. See previous provider notice dated September 3, 2021 for the additional dose instructions.
The additional dose of the Moderna or Pfizer COVID-19 vaccine is available for immunocompromised individuals who may not develop the same immune response level after vaccination as others. A customer may receive the additional dose at least 28 days after the customer's second vaccine dose.
The booster dose of the Pfizer COVID-19 vaccine is also available. A booster shot is recommended for certain individuals, as protection from the vaccine wanes over time. A customer may receive a booster dose at least six months after the customer's second vaccine dose.
Specific recommendations regarding the populations endorsed for the additional and booster vaccinations are contained in Illinois Department of Public Health's Additional Dose and Booster Shot FAQ.
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 October 14, 2021, pharmacies can begin billing claims for dates of service beginning September 24, 2021, for the booster 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|| |||| |
|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 (additional dose) in the SCC field.
- For the third dose, submit 10 (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 continue to 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