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Get Correct Payment for Immunizations and Injectables

TRICARE covers most drugs and immunizations administered in a provider's office. Immunizations and drugs administered other than orally are priced using Medicare rates for HCPCS J codes. Drugs administered in a home infusion setting and drugs that do not appear on the Medicare J code pricing file are priced at 95 percent of average wholesale price (AWP). The Medicare J code pricing file is updated on a quarterly basis. For TRICARE network providers, contracted rates are used in calculating the TRICARE allowed amount as well.  

Washington state exception: In accordance with the Washington State Childhood Vaccine Program, these billing guidelines do not apply to providers in the state of Washington. Please visit www.doh.wa.gov and www.wavaccine.org for Washington state vaccine billing guidelines.

Claim Requirements

The following information must be included in the claim: 

  • An 11-digit National Drug Code (NDC) number. If the claim does not include an NDC, the claim will be rejected for "NDC required." If an NDC code is only a 10-digit format, it must be converted to an 11-digit code. (For example, 99999-9999-9 should be converted to 99999-9999-09).
  • The corresponding CPT® or HCPCS code. 
  • The drug quantity, which indicates the dosage of the immunization administered. This number must always be greater than zero, but can be a fractional or decimal unit (such as 0.5). 
  • The drug package indicator value of P for package or U for unit.
  • The unit of measurement (for example, UN=Unit, ML=milliliter, ME=milligram, F2=international unit, or GR=gram).

Note for state agencies: For vaccines supplied by a state agency or a state run clinic, the claim should include a code for administration of the vaccine with the modifier SL. 

Visit the Centers for Disease Control and Prevention (CDC) website for recommended immunization and injectable dosage information. 

Submitting Electronic Claims

Network providers (except those in Alaska) are required to submit claims electronically. Use the following data elements to submit the NDC information in the HIPAA-standard ASC X12N 837 electronic claims format.

  • Loop 2400, segment SV101 = CPT/HCPCS code
  • Loop 2400, segment SV104 = CPT/HCPCS units
  • Loop 2410, segment LIN03 = 11-digit NDC number
  • Loop 2410, segment CPT04 = NDC quantity
  • Loop 2410, segment CPT05 = NDC unit or basis for measurement code (UN, ML, ME, F2, GR)

If you need assistance mapping your NDC information to your EDI claim, please contact our EDI Help Desk at 1-800-259-0264. You can also visit www.wpc-edi.com for detailed filing instructions for the HIPAA format. 

Submitting Paper Claims

Enter the NDC information in the shaded area of section 24 (A–G) in the following order: qualifier (N4), NDC code, one space, unit of measurement and quantity. The number of digits for the quantity is limited to eight digits before the decimal and three digits after the decimal. Do not use decimals if entering a whole number, and do not use commas.

Example:


For additional information, reference the TRICARE Reimbursement Manual (TRM), Chapter 1, Section 15.

 

 

 

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