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Immunization Toolkit: Billing

I. Billing of Immunization involves 2 separate items that may be reimbursable.

     1. The Vaccine itself   

     2. Service of Administration of Vaccine (note not all PBM will reimburse for Vaccinations and administration)

 

II. A Pharmacy becoming eligible for Medicare Part B billing will be able to bill for the following vaccines: Influenza, Pneumococcal Vaccines, and Hepatitis B

 

III. Medicare Part B often provides full payment with no deductibles for those vaccines or co-payments for patients when billed through a state Medicare B carrier.

 

IV. Pharmacies are able to bill the state Part B carrier as a mass immunization provider.

 

V. Receiving Part B reimbursement includes 2 steps:

     1. Pharmacy must have a National Provider Identification number (NPI).  Click here for more information.

     2. Apply for a Medicare Part B Provider status: application is CMS Form 855I. Click here for this form.

     3. Apply for Mass Immunization Provider Status: application is CMS Form 855B.  Click here for this form.

     4. Both the vaccine and the administration fee are compensable under Medicare Part B using the appropriate Current Procedural Terminology.  (See information inks below)

     5. Medicare Advantage-PDP plans require a separate contract from traditional Medicare B to bill for Medicare B covered vaccines.  Check with individual Medicare advantage plans for contracts and details.

VI. Medicare Part D allows for compensation of all non-Part B vaccines (ie, anything except influenza, pneumococcal, and hepatitis B) through its contracted prescription drug plan (PDP) sponsors (e.g. Zoster vaccine).

     1. Both Vaccine and Administration fee are billable.  See your pharmacy software vendor for details how to bill for vaccine via your computer system

     2. Pharmacists should consult with the applicable PDP or Medicare Advantage-PDP for detailed billing instructions.

 

VII. Private insurance companies, and state Medicaid plans  vary widely in their coverage of vaccines. For self-insured or employer-insured individuals, the major-medical benefit is most likely the portion of the insurance coverage that will cover vaccines and their administration. Just like the Medicare Advantage Plans please check with individual plans for contracts

 

VIII. Due to cost of vaccine pharmacist should verify coverage, because most vaccines cost a great deal, it is strongly advised that pharmacists verify insurance coverage before administering the vaccine.

 

IX. Out of Pocket- Patients may be willing to pay for certain vaccines for cash.  Travel vaccines are usually not covered by insurance. In addition, patients who pay cash maybe able to get reimbursed by submitting the receipt to their insurance or write of as a income tax expense.

 

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