Claims for Medicare Part D Vaccines

Certain vaccines used in certain circumstances must be covered under Medicare Part B. In order to facilitate appropriate coverage and reporting of vaccines for Medicare enrollees in compliance with Medicare rules and regulations, Medicare member vaccine coverage shall be administered as follows:

Medicare Part B Vaccines:

90732Pneumococcal
90658Influenza
90740Hepatitis B for Dialysis or immunosuppressed (3 dose)
90747Hepatitis B for Dialysis or immunosuppressed (4 dose)
90703Tetanus, for medical reason other than Preventive
90714Tetanus & Diphtheria toxoids preservative free for medical reason other than preventive
90718Tetanus & Diphtheria toxoids for medical reason other than preventive
90675Rabies, which is always given in response to exposure

 

Medicare Part D Vaccines:

Covered Medicare vaccines not listed above, which are prescribed for preventative purposes, along with their administration expense, are covered under Medicare Part D. The Pharmacy shall be responsible for determining the affected Medicare Part D vaccines. A list of examples (not to be considered as all-inclusive) of affected vaccines are as follows:

  • Adacel
  • Attnuvax
  • Boostrix
  • Comvax
  • Devavac
  • HIB Titer
  • Menactra
  • Meruvas
  • MMR
  • Mumps Varivax
  • Polio
  • Proquad
  • Typhoid
  • Yellow Fever
  • Zostavax

Tetanus/Tetanus & Diphtheria toxoids (given as a preventative, not in response to an illness or injury)

Procedure:

  1. Medicare Part B: All provider claims related to the supply and administration of Part B vaccines will be reported to FHCP's Claims Department via paper or electronic billing and include the data elements required for the submission of physician (CMS 1500) or institutional claims (UB04) for a Medicare enrollee and will be adjudicated per FHCP Policy & Procedure.
  2. Medicare Part D (Preferred Method) - Part D Vaccine Administered by FHCP Infusion/Injection Clinic:
    1. Physicians shall supply the member with a prescription for the vaccine;
    2. Members shall be directed to call the most convenient FHCP Infusion/Injection Clinic to schedule their injection;
    3. Prior to keeping their injection appointment, the member shall take their prescription to the FHCP pharmacy;
    4. The member shall pay the pharmacy for both the vaccine and its administration cost;
    5. The member shall take their FHCP pharmacy receipt to their scheduled appointment at the FHCP Infusion/Injection Clinic to have the vaccine administered;
    6. Infusion/Injection Clinic staff shall dispense and administer the vaccine;
    7. No additional payment shall be collected from the member by the Infusion/Injection Clinic.
  3. Medicare Part D Alternative Method 1 - Physician Administers Vaccine and Bills FHCP: It is anticipated that this method will be utilized by participating, non-staff physicians when there is considerable hardship due to member transportation or mobility restrictions that preclude the physician from following Method 1 (Preferred) noted above.
    1. Providers who are not aware of, or do not follow the procedure outlined in Paragraph 2.a-g above, shall submit paper or electronic claims to the FHCP Claims Department for payment of the Medicare Part D Vaccine and its administration.
    2. In order to be considered a clean claim, Part D Vaccine claims must include the following information:
      1. Member name
      2. Date of Service
      3. Administering Physician Name, address, phone number,
      4. Administering Physician NPI #
      5. Administering Physician DEA #
      6. Vaccine Name
      7. Vaccine NDC #
      8. Quantity Administered
    3. If the claim is not clean, the Claims Department pend the claim for payment and request needed data as appropriate.
    4. When required information is provided in order for the claim to be considered "Clean", the Claims Department will forward the claim to the FHCP Pharmacy Administrator or designee (hereinafter referred to as "Pharmacy").
    5. The Pharmacy will enter the prescription into the Pharmacy System to record and report the appropriate Medicare PDE, determine the allowed amount for the vaccine and the member's out of pocket expense based upon data in the pharmacy system on the date of review.
    6. The Pharmacy will return the claim to the Claims Department, noting the allowed amount for the vaccine and the member's out of pocket responsibility.
    7. The portion of the claim related to the Part D vaccine will be entered into the Claims System as follows:
      1. Diagnosis Code = Code(s) on Claim
      2. Procedure Code = VACNE
      3. Quantity = 1
      4. Billed amount = billed amount of claim
      5. Allowed amount = amount calculated by pharmacy
      6. Not covered amount = difference between billed and allowed amounts
      7. Copay amount = member out of pocket expense calculated by Pharmacy
      8. Net amount = allowed amount less member's out of pocket expense.
    8. The billing provider's Remittance Advice and the Medicare member's Explanation of Benefits will indicate that Provider should seek reimbursement from the member for the difference between the Net amount paid and the billed amount.
    9. The Provider may bill the member for the difference between the Net amount paid and the billed amount.
  4. Medicare Part D Alternative Method 2 - Physician Administers Vaccine and Bills Medicare Member:
    1. Physician administers Part D vaccine in the physicians office incidental to the physician's other services
    2. Physician collects billed amount for the Part D vaccine from the member
    3. The physician provides the member with a paid receipt for the vaccine which must include the following data elements:
      1. Member name
      2. Date of Service
      3. Administering Physician Name, address, phone number,
      4. Administering Physician NPI #
      5. Administering Physician DEA #
      6. Vaccine Name
      7. Vaccine NDC #
      8. Quantity Administered
    4. The member submits the paid receipt to the FHCP Claims Department for reimbursement
    5. The Claims Department shall review the reimbursement request to assure that the required elements are present.
    6. If all elements are present, the Claim will be considered clean and will be processed.
    7. If the claim is not clean, the Claims Department shall follow FHCP Policy and Procedure PC008, Initial Determination and Reconsideration of Medicare Beneficiary Claims to request needed data from the Member as appropriate.
    8. When required information is provided, the Claims Department will forward the claim to the FHCP Pharmacy Administrator or designee (hereinafter referred to as "Pharmacy").
    9. The Pharmacy will enter the prescription into the Pharmacy System to record and report the appropriate Medicare PDE, determine the allowed amount for the vaccine and the member's out of pocket expense based upon data in the pharmacy system on the date of review.
    10. The Pharmacy will return the claim to the Claims Department, noting the allowed amount for the vaccine and the member's out of pocket responsibility.
    11. The reimbursement request will be entered into the Claims System as follows:
      1. Diagnosis Code = Code(s) on Claim
      2. Procedure Code = VACNE
      3. Quantity = 1
      4. Billed amount = billed amount of claim
      5. Allowed amount = amount calculated by pharmacy
      6. Not covered amount = difference between billed and allowed amounts
      7. Copay amount = member out of pocket expense calculated by Pharmacy
      8. Net amount reimbursed to member = allowed amount less member's out of pocket expense.