Download the COVID-19 Vaccine Quick Reference Guide (PDF) for fee-for-service pharmacy claim processing.
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.
To learn more or to participate in the administration of COVID-19 vaccines, visit the Texas Department of State Health Services Vaccination Provider Enrollment and register through the Texas DSHS Immunization Program Portal. For questions about registration, call the DSHS COVID-19 Vaccine Provider hotline at (877) 835-7750, 8 a.m. to 5 p.m., Monday through Friday or email COVID19VacEnroll@dshs.texas.gov.
HHSC set the fee-for-service (FFS) reimbursement rate to align with Medicare. For vaccines requiring two doses, the FFS initial dose’s administration reimbursement rate is $16.94, and the final dose is $28.39. 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, pharmacy staff should submit the following:
- Submit the 10-digit National Provider Identifier (NPI) of the administering pharmacist (or supervising pharmacist of the pharmacy staff administering the vaccine) in the “Prescriber ID” field (411-DB). Pharmacy staff without an NPI (e.g., intern) should use the supervising pharmacist’s NPI instead. This field is required on all claims.
- Individuals or organizations apply for NPIs through the CM National Plan and Provider Enumeration System (NPPES).
- Submit the value “05” in the “Prescription Origin Code” field (419-DJ).
- 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 (42Ø-DK) to indicate the first dose of a multi-dose vaccine. Pharmacies must submit the final dose with a value of “06” (Starter Dose) in field 42Ø-DK.
Additionally, for fee-for-service claims, pharmacies may receive a rejection when submitting a second dose claim if the first dose was given at 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)
Pharmacy staff should refer to the Medicaid billing transaction payer specifications for fee-for-service claim submission guidance.
Pharmacy staff and providers can search for COVID-19 vaccines through the Product Search.
January 6, 2021
COVID-19 Vaccine NDC Update
January 4, 2021
Drug Shortage Notification Process Available
December 22, 2020
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December 21, 2020
Medicaid Adds Pfizer BioNTech COVID-19 Vaccine to Formulary
- TPA: Instructions for Pharmacists to Apply for a NPI (PDF) (Dec. 2020)