Summarized billing recommendations for 2009
H1N1 vaccine
Organizations provide guidance to aid
pharmacists in billing for 2009 H1N1.
Public payers
CMS: Fee-for-service policies,
procedures for providers in H1N1 pandemic
In late August, CMS issued information
on Medicare
fee-for-service policies and procedures in an H1N1 flu pandemic or other
public health emergency or disaster. The 22-page document addresses
issues related to H1N1 vaccination, flexibilities available in an
emergency or disaster, waivers of certain Medicare requirements in a
declared emergency or disaster, and payment polices and billing
procedures for various types of health care services and providers.
Private payers
Pharmacists may bill for H1N1 vaccine
administration to private payers in three ways: (1) through the pharmacy
system, (2) via roster bill, or (3) via cash receipt. The mechanism used
depends on individual plans. Pharmacies will need to contact plan
administrators to determine the appropriate process to use.
(1) Pharmacies with existing relations
with plans to bill via the pharmacy claim system or agreement by plan to
use this system: Billing consistency recommendations from
NCPDP
A task group of the National Council for
Prescription Drug Programs (NCPDP) recently recommended that, when
billing for a vaccine (e.g., 2009 H1N1) as part of a drug benefit, the
same method should be used as that defined for Medicare Part D vaccine
administration billing. Therefore, the pharmacy should submit the
following fields:
Ingredient Cost Submitted (4Ø9-D9) (contains
ingredient cost for vaccine, which may be zero for a government-supplied
product) Dispensing Fee Submitted (412-DC) (zero for H1N1
claims) Incentive Amount Submitted (438-E3) in the Pricing
segment
(contains administration fee) Gross Amount Due (43Ø-DU) (contains summation
of the preceding three fields) DUR/PPS Segment (contains DUR/PPS Code Counter
[473-7E] of 1 and Professional Service Fee Submitted [44Ø-E5] with
a value of MA [medication administered])
Then, the payer responds with the following
fields:
Ingredient Cost Paid (5Ø6-F6) Dispensing Fee Paid (5Ø7-F7) Incentive Amount Paid (521-FL)
More information is available in an NCPDP
document titled Version 5
Editorial on the NCPDP website.
Also, when rejecting the claim for a vaccine
that is not part of a drug benefit, NCPDP recommends that the payer use
Reject Code (511-FB) of "7Ø" (Product/Service Not Covered), along
with any additional messaging that the plan might know to help the
provider determine a follow-up course of action.
(2) Pharmacies billing through medical
claims or without preexisting relationship with plan: Roster billing for
H1N1 vaccine administration
America’s Health Insurance Plans (AHIP),
working with its member plans, the American Pharmacists Association, the
National Association of Chain Drug Stores, the National Community
Pharmacists Association, the National Association of State Pharmacy
Association Executives, pharmacy providers, and other stakeholders,
developed a roster
bill format in Excel that will be useful for pharmacies and
health plans when billing for H1N1 vaccine administration.
The Excel spreadsheet is an H1N1-specific
roster billing model that pharmacies and plans should consider using. It
attempts to balance the traditional medical claims submission
requirements from the health plans with the intake and billing
requirements from the pharmacy environment. However, the spreadsheet
model is not an intake tool for pharmacies. The expectation is that
pharmacies, through standard electronic (and possibly manual) processes,
will transfer patient-acquired data elements into the roster bill.
Additional information is available in a
previous Ask
the Expert article published at APhA’s Pharmacist
Immunization Center.
(3) Patients paying cash and
submitting claim for reimbursement to plan
HHS Secretary Sebelius has requested that all
parties involved “decrease the barriers to vaccination and
minimize the administrative complexity of providing access and financing
for the administration of this vaccine.” Cash payment for the
administration of this public health pandemic vaccine is a potential
barrier to vaccination and may place a burden on those seeking this
important service. Providers and payers are encouraged to consider
billing approaches that reduce the burden on patients.
If pharmacies elect to charge insured patients
up-front for administration of the H1N1 vaccine, pharmacies should
provide their customers with a receipt that includes the following
information:
Provider name Provider address, city, state, ZIP Code Provider NPI Provider Tax ID Diagnosis code Vaccine code Administration code Date of service Charge amount Amount patient paid Patient name Medical benefits ID member number and group
number Patient date of birth
Patients can submit for reimbursement through
their health plan’s established methods and may also need to
submit a form with information not captured on the pharmacy receipt.
Pharmacies can assist patients with completion of their claim form, if
needed.
Web links
Related resources on
pharmacist.com
Resource
Joe Sheffer (jsheffer@aphanet.org)
Posted October 22, 2009
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