Submitting Pharmacy Claims for COVID-19 Vaccinations
You can now submit claims for COVID-19 vaccines. During the Public Health Emergency (PHE), Horizon Blue Cross Blue Shield of New Jersey (Horizon BCBSNJ) and Horizon NJ Health will align with the Centers for Medicare & Medicaid Services (CMS) guidelines for the billing and reimbursement for the administration of COVID-19 vaccines.
COVID-19 vaccines and administration are 100 percent covered through in- and out-of-network pharmacies during the PHE.
Claim Submission Requirements
Pharmacies administering COVID-19 vaccines to eligible members must adhere to the following requirements for submitting claims to Horizon BCBSNJ. All pharmacies must:
- Meet state and federal regulations for receiving and administering vaccines.
- Follow the Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices (ACIP) clinical guidelines for vaccine administration.
Claim Billing
- Please bill only for the vaccine administration during the PHE. At this time, claims submitted for the vaccine serum will be denied because the initial supply of COVID-19 vaccines are federally purchased and distributed to providers at no charge. If this changes and vaccines become available for direct purchase by providers, updated guidelines will be provided.
- Please submit claims for vaccine administration through the member’s pharmacy benefit during the PHE and follow National Council for Prescription Drug Programs (NCPDP) standards.
- For Medicare, please submit claims for COVID-19 vaccine administration to Original Medicare through your Medicare Administrative Contractor (MAC).
Per NCPDP guidelines, pharmacies should include the following codes when billing for the Single Dose Vaccine and for the Initial Dose of Multi-Dose Vaccines:
| Field | Enter Value | Description |
|---|---|---|
| Professional Service Code (440-E5) | MA | Value of MA (Medication Administered) |
| Incentive Amount Submitted (438-E3) | >$0 | Value greater than $0 to indicate that the submitted claim is for the vaccine administration |
| Submission Clarification Code (420-DK) | 2 | Submission Clarification Code of 2 "Other Override" |
Per NCPDP guidelines, pharmacies should include the following codes when billing for the Second Dose of Multi-Dose Vaccines:
| Field | Enter Value | Pharmacy-populated values |
|---|---|---|
| Professional Service Code (440-E5) | MA | Value of MA (Medication Administered) |
| Incentive Amount Submitted (438-E3) | >$0 | Value greater than $0 to indicate that the submitted claim is for the vaccine administration |
| Submission Clarification Code (420-DK) | 6 | Submission Clarification Code of 6 "Starter Dose" |
Pharmacy COVID-19 Administration Fees:
During the PHE, Horizon BCBSNJ will reimburse pharmacies for administration of COVID-19 vaccines to eligible members at the below rates.
| Vaccine/Dose | Administration Fee |
|---|---|
| Single Dose Vaccine | $28.39 |
| Multi Dose Vaccine/Initial Dose | $16.94 |
| Multi Dose Vaccine/Final Dose | $28.39 |
Participating pharmacies that have ancillary service agreements with Horizon BCBSNJ:
The February 2021 update to your fee schedule will include the information below. However, during the PHE, please continue to submit claims through the members’ pharmacy benefit.
| Code | Description | Allowance |
|---|---|---|
| 0001A | ADM SARSCOV2 30MCG/0.3ML 1st Pfizer-BioNTech Covid-19 Vaccine Administration – First Dose | $16.94 |
| 0002A | ADM SARSCOV2 30MCG/0.3ML 2nd Pfizer-BioNTech Covid-19 Vaccine Administration – Second Dose | $28.39 |
| 0011A | ADM SARSCOV2 100MCG/0.5ML 1st Moderna Covid-19 Vaccine Administration – First Dose | $16.94 |
| 0012A | ADM SARSCOV2 100MCG/0.5MLnd Moderna Covid-19 Vaccine Administration – Second Dose | $28.39 |
| 0021A* | ADM SARSCOV2 5X10^10VP/.5ML 1st AstraZeneca Covid-19 Vaccine Administration – First Dose | $16.94 |
| 0022A* | ADM SARSCOV2 5X10^10VP/.5ML 2nd AstraZeneca Covid-19 Vaccine Administration – Second Dose | $28.39 |
*Though included in the table above, the AstraZeneca vaccine is not yet available as of January 22, 2021. Stay up to date.
When the PHE ends, Horizon BCBSNJ will reassess billing codes and the reimbursement rates for the vaccine administration costs and communicate any updates to you.
Questions?
For Commercial/Medicare inquiries, please email John Thornton at John_Thornton@HorizonBlue.com.
For Horizon NJ Health inquiries, please call our Pharmacy Help Desk at 1-800-682-9094, extension 81016, weekdays, 8 a.m. to 6 p.m., and Saturday, 8 a.m. to 4:30 p.m.
