Billing for COVID-19 Vaccines

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The following instructions are for setting up to bill insurances for the 2-dose COVID-19 vaccine. As of the creation of this guide, this info has only been tested on the MODERNA vaccine, not the PFIZER vaccine, but the same information should be applicable.

Insurances require that COVID Vaccines be billed with an AWP value of $0.01, but will pay an administration fee to cover the labor of dispensing the vaccine.

If you require assistance in setting up or billing a vaccine, please contact Cost Effective Computers, and an agent will assist you. An update may be required to ensure all the features discussed below work properly. It should require no more than 5 minutes to perform.

Setup a 1-cent Price Table

A special price table is required to correctly bill the vaccine.

  1. From the Rx Processing Menu select option 15 "Price Table Maint.
  2. Search for Table 99
  3. Hit Next or Previous a few times and take note of price table numbers, and look gaps in the sequence; these are unused tables. When you've found a number that is not used, write it down, as this will be the new table you create.
  4. Choose A to Add a new table. Assign it the number you chose from the previous step, and give it the description 1 Cent COVID
  5. Setup the following columns (or use the image provided below as a guide)
    1. Line 3: 999999.00
    2. Line 4: -99.99
    3. Line 5: 0.01
  6. After adding the last value, press escape to skip to the bottom of the screen.
    1. Line 123 should be D
    2. Line 124 should be A
  7. E to Exit

Example Price Table

Setup the Vaccine

You will need to create TWO versions of the Vaccine on your Drug File Maint. This is because some insurances want a $25.00 cost per injection, while others want only $0.01 cost per injection. Sending the incorrect value will cause the insurance to not reimburse properly.

On the First Version of the vaccine, setup as you would any other drug (Name, NDC, Package Quantity, etc.) But with the following changes:

  • Set AWP and ACQ to $250.00 (Calculates to $25.00 per shot)
  • Keep the default price table on line 5 (usually table 99)
  • Make sure to include Expiration date (line 9), as 2-digit month, a slash, and 2-digit year (ex 12/21).

Use the image provided below as a guide.

Example COVID Drug

Setup the Second Version of the vaccine with the following exceptions:

  • Give it a different name from the original, indicating that this vaccine bills only a penny for INGREDIENT COST. Example "Moderna COVID 0.01"
  • Whatever the Package Quantity is on Line 6, set the AWP value on on Line 16 to be that many cents. (Example: if the quantity is 1, then set AWP to be $0.10)
  • Set line 5 Price Table to match the price table you setup in the previous section.
  • Set the following codes on Line 39, Price Codes (pick them from the menu options listed)
    • Disable Rounding Table
    • Use Drug U&C Price NOT 3pI Price
    • Exclude Drug from Minimum Price

Use the image provided below as a guide.

Example COVID Drug

If you are unsure which drug to bill, try the first one (with the $250 AWP) and see if the insurance bills correctly. If it does not, reverse and try the penny version.

Notes on Lot Numbers

Certain states require that the pharmacy track lot numbers, and submit them to GRITS (or the state equivalent) online vaccine database. To our knowledge:

  • Alabama does NOT require lot numbers.
  • Georgia does NOT require lot numbers, except for deducting inventory.
  • Tennessee DOES require lot numbers.

There are three different ways you can set lot numbers to drugs in QuickSCRIP:

Set the Lot Number in the Drug File

  1. Look up the drug in the Drug File Maintenance Screen
  2. One Line 38 Code there is a menu option Lot Number. This will need to be updated manually, as number change.

Ask for the Lot Number in the Fill Screen

  1. Look up the drug in the Drug File Maintenance Screen
  2. One Line 38 Code there is a menu option Get Lot # For This Drug.
  3. Exit the Drug File Screen
  4. Go to the Pharmacy Main Menu
  5. Type UB to go to the Business Control File
  6. Select Option 4 Additional RX Custom Screen 1
  7. On Line 15 Get Lot Number on RX set to X. This will have QuickScrip prompt you for the lot number on marked drugs during the fill process.

Add it in QuickSHOTS before sending to GRITS

Quickshots gives you the opportunity to review your vaccine info before submitting them to the state. There is a field in the program that allows you to manually enter or edit lot numbers.

Billing Medicare Part B

Medicare part B subcontracts its claim billing to other companies, who may have additional requirements for billing COVID-19 Vaccines.

For FDS and CAM (Cardinal)

FDS plans to use HCPS codes (alternatively called Procedure Codes) to distinguish between the first and second doses. See this Medicare link for a full list of procedure codes.

These codes are sent as /PC=xxxxx in the SIG lines of RXFILL or EDIT.

  • Moderna dose 1 is 0011A
  • Moderna dose 2 is 0012A
  • Pfizer dose 1 is 0001A
  • Pfizer dose 2 is 0002A

Note: Insurance reimbursement is different between the 1st and 2nd dose.

To send HCPS codes, you will also need to add a switch to your Medicare B insurance.

  • Look up the insurance plan in you Insurance File Maint. database.
  • Type O3 to go to Screen 3
  • On line 16, add /PC to the end of any code that is already present on that line.

Additionally, you will need to send an ICD-10 code of /IC=Z23 in the SIG lines, which indicates that a vaccine was dispensed.

For EBS

EBS will be using the group number to distinguish between first the first and second doses.

  • For the first dose, set the group number to FIRST or 1st.
  • For the second dose, set the group number to SECOND or 2nd.

Billing the Vaccine in the Fill Screen

Setup the prescription to bill an insurance as you would normally. Add the following commands to the SIG lines:

  • Submission Clarification Code: /XD02 for First Dose, or /XD06 for second dose
  • DUR Codes: /DUIMA (DUR codes may be different from insurance to insurance)
  • Administration Fee: /ADMFEE$20.00 (or however much you wish to bill for the admin fee)

COVID SIGs

Transmit the claim, see if it is accepted, and take note of how much of the administration fee the insurance pays. To help track customers who have been administered their first dose, you can use the Manual Refill Queue to set a reminder for the second dose one month later.