Billing Tips for Immunizations
Tuesday, March 19, 2019
revised April 11, 2019
TRICARE covers age-appropriate immunizations and vaccines in accordance with Centers For Disease Control and Prevention (CDC) age and frequency recommendations. In order to help you better understand pricing and billing guidelines, Health Net Federal Services, LLC (HNFS) offers the following tips. Please note: PBGA, LLC, HNFS’ claims processing partner, recently updated the maximum dosage amounts for immunizations in its systems to ensure alignment with the CDC and proper reimbursement. PGBA will automatically adjust and reprocess any impacted claims.
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.
The following information must be included on claims for injectables:
- An 11-digit National Drug Code (NDC) number, unique to the manufacturer of the drug. If an NDC code is only 10 digits, convert it to an 11-digit code when billing. (For example, convert 99999-9999-9 to 99999-9999-09). Always use the 5-4-2 format (five digits, four digits, two digits) on the claim. HNFS will deny claims without an NDC or with an incorrectly formatted NDC with the reason "NDC required."
- The corresponding CPT® or HCPCS code
- The drug quantity, which indicates the dosage (see below)
- The drug package indicator value (P = package, U = unit)
- The unit of measurement (UN = unit, ML = milliliter, ME = milligram, F2 = international unit, GR = gram)
- For vaccines supplied by a state agency or a state run clinic, a code for administration of the vaccine with the modifier SL
Providers are required to indicate the correct dosage value in the NDC drug quantity field on the claim form. This number must always be greater than zero, but can be a fractional or decimal unit (such as 0.5). A drug quantity of 1.0 indicates a 1.0 mL dosage was administered, whereas a drug quantity of 0.5 indicates a 0.5 mL dosage was administered. In most cases, the NDC quantity will be different from the HCPCS billed units. Reimbursement is based on the CDC’s recommended dosages. If you bill a drug quantity of 1.0 for a drug with a recommended dosage of 0.5 mL (for example, Menactra®), you will only be reimbursed for 0.5 mL. Visit www.cdc.gov for recommended immunization dosage information.
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)
Electronic billing allows for up to two digits behind the decimal point for the dosage (for example, 0.5).
Visit www.wpc-edi.com for detailed electronic filing instructions. If you need assistance mapping your NDC information to your electronic data interchange (EDI) claim, contact our EDI Help Desk at 1-800-259-0264.
Non-network providers and providers in Alaska who submit paper claims must enter the NDC information in the shaded area of section 24 (A–G) of the 1500 claim form in the following order: qualifier (N4), NDC code, one space, unit of measurement, quantity. The digit limit for the quantity is 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. Visit the National Uniform Claim Committee’s website at www.nucc.org for complete instructions.
Find links to these and other billing tips on our Billing Tips and Reimbursement Rates page.