The NCPDP Emergency Preparedness Task Group approved a guidance document for the industry, related to the administration of the COVID-19 vaccines.
Subject to section 2713 of the Public Health Emergency Act, plans must cover without cost sharing such an immunization and its administration, regardless of how the administration is billed, and regardless of whether a COVID-19 vaccine or any other immunization requires the administration of multiple doses in order to be considered a complete vaccination.
These vaccines will generally be available through the Food and Drug Administration (FDA) Emergency Use Authorization (EUA) process, and may vary in strength, dose quantity and number of doses to achieve expected efficacy. COVID-19 vaccines currently under FDA review will require a series of two doses to achieve expected efficacy. Reimbursement for administration of these doses may vary for each dose within the series. NCPDP recommends:
Two-Dose Vaccines: Use of Submission Clarification Codes (420-DK)
In order to clearly identify whether the claim is for an initial dose or final dose of the vaccine series — in addition to the Professional Service Code MA — a Submission Clarification Code value should be submitted on all claims for two-dose vaccines. The following distinct Submission Clarification Code values should be used to clarify the submission as an initial or final dose:
- Submission Clarification Code of 2 “Other Override” – defined as, “Used when authorized by the payer in business cases not currently addressed by other SCC values,” to indicate the first dose of a two-dose vaccine is being administered.
- Submission Clarification Code of 6 “Starter Dose” – defined as, “The pharmacist is indicating that the previous medication was a starter dose and now additional medication is needed to continue treatment,” to indicate the final dose of a two-dose vaccine is being administered.
For details, refer to the NCPDP EMERGENCY PREPAREDNESS GUIDANCE – COVID-19 VACCINES document on the NCPDP.org website.