Date: January 11, 2022
To: Pharmacy Providers
Re: Pharmacy Billing of Subcutaneous Monoclonal Antibody Treatment
Pharmacy providers who formalize an agreement with the Illinois Department of Public Health (IDPH) will be able to prescribe, dispense and administer the subcutaneous monoclonal antibody medication REGEN-COV (casirivimab and imdevimab) medication to Medicaid customers who test positive for COVID-19. The specific instructions below apply to Medicaid fee-for-service claims, but the Medicaid HealthChoice Illinois managed care plans will also reimburse these claims through NCPDP claim submission.
The Illinois Department of Healthcare and Family Services (HFS) will reimburse Medicaid participating pharmacies an administration incentive fee through NCPDP claim submission. The Illinois Medicaid incentive amounts are $750.00 for treatment administered in the home and $450.00 for treatment administered in a pharmacy. The entity billing is responsible for ensuring the correct amount is billed and appropriate documentation is maintained.
Pharmacies can begin billing claims as of December 30, 2021 for dates of service beginning November 1, 2021, via an electronic NCPDP claim according to the following instructions:
- Submit each treatment with the specific approved 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.
- Submit Quantity Dispensed (442-D7) with the value that represents the quantity of drug/ product administered.
- Submit Days Supply (405-D5) with a value of "1".
- Submit the product administration fee (either $450 or $750) in the Incentive Amount Submitted field (438-E3) on the same claim as the product (i.e., ingredient).
- If the prescriber is not a pharmacist, submit the NPI of the prescriber in the Prescribing Practitioner (411-DB) field.
- If a pharmacist is the prescriber, submit the NPI of the prescriber (pharmacist) in the Prescribing Practitioner (411-DB), submit a Submission Clarification Code (420-DK) of "42", and the Prescription Origin Code (419-DJ) would be "5 "– Pharmacy.
Note: HFS will be releasing information soon regarding oral antibody treatment via separate provider notice.
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