Reimbursement
Loren Bonner
It’s hard to know how widespread COVID-19 vaccination reimbursement issues are for pharmacists across the country. In Arizona, Kelly Fine, RPh, CEO of the Arizona Pharmacy Association, said they are still experiencing issues with successfully applying Advisory Committee on Immunization Practices (ACIP) recommendation changes for the COVID-19 vaccine with some Medicaid-managed care plans and with other plans.
She said some pharmacies in her state have received failed COVID-19 vaccine reimbursement claims for newly approved groups such as pediatrics weeks after ACIP issued recommendations. Some insurance companies are not recognizing the Moderna 0.25 mL COVID-19 vaccine as a covered service, for example.
“[This] causes a significant burden and time to rebill, with multiple attempts per claim to eventually receive a paid claim,” said Fine.
Pharmacists are encouraged to contact their state pharmacy association or APhA if they encounter reimbursement issues. APhA has also developed a resource page with helpful tips and information (apha.us/COVIDvaxReimbursement). The page contains an NCPA tool that pharmacists can use to report reimbursement issues as well.
The “key takeaways” from that resource page are included in the sidebar.
Insurance information
Reimbursement rates for COVID-19 vaccine administration and related services depend on the patient’s insurance and whether the claim is billed to the insurer as a medical claim under the medical benefit, or as a pharmacy claim under the pharmacy benefit.
Patients need to present their insurance information, which may require some understanding on the patient’s part, according to Fine. In order to encourage vaccination early on, the public heard the message that no insurance was needed to receive a COVID-19 vaccine. However, Fine said this has led to patients refusing to present their insurance information to pharmacists.
Pharmacy systems can find patient’s insurance information in 60% to 80% of cases, but not all.
“If insurance is not located, the claims are billed to HRSA, but sometimes the government can then locate the insurance and deny the claim—but unfortunately cannot share the insurance information for claim rebilling,” said Fine. ■
Key takeaways for COVID-19 vaccine reimbursement
- Patients should not have any out-of-pocket costs for receiving a COVID-19 vaccine, per federal mandate.
- To be reimbursed as a COVID-19 vaccine provider, pharmacists who do not have a Type 1 (individual) National Provider Identifier (NPI) should apply for a number. Pharmacy reimbursement claims for COVID-19 vaccines must include 2 NPI numbers: a Type 1 (individual) NPI number unique to the provider who has ordered/prescribed the vaccine and a Type 2 (Provider Organization) NPI number for the pharmacy responsible for providing the vaccine.
- Pharmacies may have multiple Provider Transaction Access Numbers (PTANs) depending on their Medicare enrollments, so it is important to use the appropriate PTAN when submitting claims. The pharmacy should use the PTAN assigned during enrollment as a Pharmacy or Mass Immunizer when submitting a COVID-19 vaccine claim.
- Collect the patient’s medical insurance card, pharmacy benefit card, and Social Security Number to enable claims billing for medical or pharmacy claims or to seek reimbursement from the HRSA Provider Relief Fund or Coverage Assistance Fund.
- Medicare patients, including patients with a Medicare Advantage plan, should be advised to provide their Red, White, and Blue Medicare card because all claims must be billed as fee-for-service.
- For Medicare and Medicare Advantage enrollees who do not have their original Red, White, and Blue Medicare card, pharmacists can use the beneficiary’s first name, last name, date of birth, and Social Security Number to look up beneficiaries’ Medicare Beneficiary Identifier (MBI) in their regional Medicare Administrative Contractors (MAC’s) secure portal to file claims for vaccine administration.
- If the pharmacy is not enrolled as a network provider with a state Medicaid or private sector plan, claims for COVID-19 vaccine administration can be submitted as an out-of-network claim.
To see the full list and for more information, visit APhA’s resource page: apha.us/COVIDvaxReimbursement