NCPDP Releases Updated Emergency Preparedness Guidance
NCPDP Releases Updated Emergency Preparedness Guidance on Additional Doses of the COVID-19 Vaccine
The NCPDP Emergency Preparedness Task Group approved a new revision of the NCPDP Emergency Preparedness Guidance v1.10 document for the industry. The new revision addresses how to handle additional doses of the COVID-19 vaccines.
NCPDP recommends:
Additional Doses
An additional dose may be administered to an individual patient based on patient-specific criteria found in the Emergency Use Authorizations (EUA), FDA-approved label or Advisory Committee on Immunization Practices (ACIP) recommendations. According to the CDC, an additional dose is defined as an additional dose of vaccine given to a targeted population from the same formulation of vaccine currently on the market. New formulations of a vaccine would have a different NDC and do not constitute an additional dose under this definition.
When a patient requires an additional dose of a specific Product/Service ID (407-D7), an additional identifier within the claim request may be necessary to specify the additional dose situation. NCPDP recommends the SCC value of 7 “Medically Necessary,” be used in claim requests for additional doses. Payers may need to modify current utilization edits to allow processing of an additional dose of the vaccine. Plans are reminded to communicate any plan-specific claims submission requirements. The use of ICD-10 codes as the sole means of communicating an additional dose is discouraged.
New formulations of the vaccine will have distinct NDCs (i.e., different from the existing) where the Product/Service ID (407-D7) value would identify the product administered as a distinct product. Existing logic for single or multiple doses should be leveraged to apply applicable claim utilization rules. Rejecting claims for therapeutic duplication based on prior claims for a different NDC is discouraged.
For details, refer to the NCPDP EMERGENCY PREPAREDNESS GUIDANCE V1.10 document on the NCPDP.org website.
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Special Edition – Monday, August 16, 2021 COVID-19 Vaccines Additional Doses: Codes & Payment The FDA amended the emergency use authorizations (EUAs) for both the Pfizer BioNTech COVID-19 vaccine and the Moderna COVID-19 vaccine to allow for an additional dose in certain immunocompromised people. Effective August 12, 2021, CMS will pay to administer additional doses of COVID-19 vaccines consistent with the FDA EUAs, using CPT code 0003A for the Pfizer vaccine and CPT code 0013A for the Moderna vaccine. We’ll pay the same amount to administer this additional dose as we did for other doses of the COVID-19 vaccine (approximately $40 each). We’ll hold and then process all claims with these codes after we complete claims system updates (no later than August 27). Learn more about Medicare COVID-19 vaccine: |
