Vaccine Immunization Claims Can Be Submitted on Pharmacy Claims for NC Medicaid Direct Beneficiaries

Effective Dec. 1, 2022, pharmacy providers who administer immunizations at pharmacies may bill NC Medicaid Direct for vaccines on pharmacy claims

Effective Dec. 1, 2022, pharmacy providers who administer immunizations at their pharmacies will be allowed to bill NC Medicaid Direct for vaccines on pharmacy claims. Immunizing pharmacists are not required to submit vaccine administration claims on medical 837P or CMS 1500 form, but this will remain an option for immunizing pharmacists who wish to do so.   

An immunizing pharmacist shall administer only those vaccines or immunizations permitted by G.S. 90 85.15B and shall do so subject to all requirements of that statute and the NC Board of Pharmacy rules.

In 2016, the Department of Public Health prohibited pharmacies from participating in the Vaccine for Children program, hence Medicaid only reimburses vaccinations by pharmacist immunizers to Medicaid beneficiaries 19 years of age and older (exception is made for COVID-19 vaccines as set forth by the 9th amendment to the PREP act for the duration of its effect, also found in the Federal Emergency PREP Act). 

Claims will deny if the beneficiary is less than 19 years of age unless the claim is pre-approved for pharmacy administration reimbursement OR if the vaccine administered is unapproved for administration by a pharmacy immunizer. 

Reimbursement rates for vaccines will be WAC+3%, and will be listed on the Outpatient Pharmacy webpage, under the Reimbursement section.  

CPT codes for administration of a vaccine will not be required on the pharmacy claim. Vaccine administration rates will be added to the reimbursement amount of the vaccine and will be reflected on the response transaction 

Administration rates for pharmacy immunizations will remain the same as for all other NC Medicaid recognized medical providers and can be found on the Physician Fee Schedule:

  • Administration rate for beneficiaries younger than 21 years is $20.45
  • Administration rate for beneficiaries 21 or older is $13.30
  • Administration rate for COVID-19 vaccinations for beneficiaries 3 years and older is $65.00

Additional information for vaccine administration on pharmacy claims:

  • Providers shall bill with the 11-digit vaccine NDC associated with the product administered (best practice is to use the NDC closest to the drug administered)
  • Providers shall bill their usual and customary charge for non-340B drugs
  • Providers shall bill their actual acquisition charge for 340B drugs in the U&C field
  • Dispensing fee will NOT be paid on pharmacy claims for immunization administration
  • Claims for vaccines shall be copay exempt
  • Vaccine claims submitted by the I/T/U provider will not be reimbursed the OMB Encounter rate (flat rate)
  • A delivery fee will not be paid on claims for vaccines
  • Vaccine claims with dates of service before Dec. 1, 2022, cannot be submitted as pharmacy claims with NC Medicaid Direct

Contact

NCTracks Pharmacy Call Center: 866-246-8505

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