COVID-19 Vaccine

On Jan. 31, 2020, the Secretary of Health and Human Services declared the 2019 novel coronavirus (COVID-19) was a public-health emergency for the United States as of Jan. 27, 2020. In Dec. 2020, the Food and Drug Administration (FDA) began issuing Emergency Use Authorizations for COVID-19 vaccines.

Immunization Program Portal

The federal government distributes the COVID-19 vaccines. Pharmacies, retail clinics, providers, and any other care site receiving and administering the COVID-19 vaccine must complete the Centers for Disease Control and Prevention (CDC) COVID-19 Vaccination Program Provider Agreement. To complete this agreement, Texas providers must enroll through the Texas Department of State Health Services (DSHS) Immunization Program Portal. This enrollment is an essential step to receive and administer vaccines for the duration of the program.

Contact the DSHS Immunization Program to participate in the administration of COVID-19 vaccines.

Claim Processing

HHSC set the fee-for-service (FFS) reimbursement rate to align with Medicare. For vaccines requiring a single or two doses, the FFS initial dose’s administration reimbursement rate is $40.00. HHSC bases reimbursement on the submitted value in the “Incentive Amount Submitted” field (438-E3). The claim will pay $0 if the field is blank.

The Public Readiness and Emergency Preparedness Act allows certain providers to order and administer the COVID-19 vaccine, including pharmacists and pharmacy interns. To process a pharmacy claim in Medicaid FFS and managed care for the vaccine administration, the pharmacy should submit the following:

  • Submit the 10-digit National Provider Identifier (NPI) of the administering pharmacist (or supervising pharmacist of the person administering the vaccine) in the “Prescriber ID” field (411-DB). A person without their own NPI (e.g., intern) should use the supervising pharmacist’s NPI instead. HHSC requires this field on all claims.
    • Individuals or organizations apply for NPIs through the National Plan and Provider Enumeration System (NPPES).
  • Submit the value “05” in the “Prescription Origin Code” field (419-DJ).
  • Pharmacies submitting claims for the single dose of a COVID-19 vaccine will not have to submit a value in the “Submission Clarification Code” field (420-DK).
  • Pharmacies submitting claims for the initial dose of a COVID-19 vaccine must use the value “02” (Other Override) in the “Submission Clarification Code” field (420-DK) to indicate the first dose of a multi-dose vaccine.
  • Pharmacies submitting claims for the second dose of a COVID-19 vaccine must use the value “06” (Starter Dose) in the “Submission Clarification Code” field (420-DK) to indicate the final/second dose of a multi-dose vaccine.
  • Pharmacies submitting claims for an additional dose of a COVID-19 vaccine must use the value “07” (Medically Necessary) in the “Submission Clarification Code” field (420-DK) to indicate an additional dose intended for immunocompromised clients.
  • Pharmacies submitting claims for a booster dose of a COVID-19 vaccine must use the value “10” (Meets Plan Limitations) in the “Submission Clarification Code” field (420-DK) to indicate a booster dose for individuals with waning immunity. This includes individuals 65 years of age and older, long-term care facility residents, individuals 18 years of age and older with underlying medical conditions, and individuals 18 through 64 years of age at increased risk for exposure and transmission due to occupational or institutional setting.

Additionally, pharmacies may receive a rejection for fee-for-service claims when submitting a second dose claim if a client received their first dose from a non-Medicaid pharmacy. If your second dose claim is correct, the pharmacy can submit the following to bypass the rejection:

  • Value “PP” (Plan Protocol) in the “Reason for Service Code” field (439-E4)
  • Value “MA” in the “Professional Service Code” field (440-E5)
  • Value “3N” in the “Result of Service Code” field (441-E6)

Refer to the Claims Billing (B1) Transaction payer sheets for specific transaction, segment, and field requirements.

Vaccine Search

Refer to the Formulary search for the list of available COVID-19 vaccines.