COVID-19 Vaccines

Non-participating and participating providers and pharmacists can follow the same instructions when billing COVID 19 vaccines. This includes physicians and physician extenders, including those practicing in a County Health Department, Federally Qualified Health Center or Rural Health Clinic.

Billing instructions for both network and non-par providers can be found online:

• Sunshine Health: Provider Billing Manual (PDF) on Page 3
• Staywell Health Plan: Download the guidelines on the Claims web page. Click on “837 Professional FFS Claims 5010v Guide” for providers or “2015 837 Institutional FFS Claims 5010v Guide” for hospitals or providers that bill on a UB04. Guidance is on Pages 9 and 10.
• Children’s Medical Services Health Plan: Download the guidelines on the Claims web page. Click on “837 Professional FFS Claims 5010v Guide” for providers or “2015 837 Institutional FFS Claims 5010v Guide” for hospitals or providers that bill on a UB04. Guidance is on Pages 9 and 10.

Similar to other COVID-19 services, the vaccines are offered at no cost to your patients. In addition: 

• Providers should bill Staywell using Plan Payer ID 14163
• Providers should bill Sunshine Health using Plan Payer ID 68069
• Providers should bill CMS Health Plan using Plan Payer ID 14163
• No prescription or prior authorization is needed for all provider types, regardless of network status

See additional pharmacy guidance below.

• Submit ‘MA’ in the Professional Service Code field (44Ø-E5) of the DUR/PPS Segment along with a positive incentive fee amount in the Incentive Amount Submitted field (438-E3) of the Pricing Segment when administering vaccines.
• Submit the appropriate Quantity (e.g., 0.5 ml) and Days Supply of “1”. Inappropriate Quantities or Days Supply may cause the claim to reject.
• If the claim initially rejects with the message “Prescriber Type 1 NPI Required” when submitted using the pharmacy NPI as the Prescriber ID (NCPDP Field 411- DB), resubmit with submission clarification code (SCC) 42. Please contact the CVS Caremark Pharmacy Help Desk for any additional questions related to claims processing.

Government-Supplied Vaccine Programs*

When submitting administration claims for a COVID-19 vaccine provided without cost through a government COVID-19 vaccine program, pharmacies must populate specific values in the following fields:

*Providers submitting claims for COVID-19 vaccine paid for by the federal government through funding authorized by the Coronavirus Aid, Relief and Economic Security (CARES) act, or paid for by any program supplying Provider with no associated cost (zero cost) COVID-19 vaccine, shall submit claims with either $0.01 in the Ingredient Cost Submitted field (NCPDP field 4Ø9-D9) or the combination of $0.00 in the Ingredient Cost Submitted field (NCPDP field 4Ø9-D9) and a value of “15” in the Basis of Cost Determination field (NCPDP field 423-DN).

Reminder: Applicable reimbursement includes a comparison to the Provider’s submitted Usual and Customary Charge (426-DQ) and Gross Amount Due (430-DU), including where the vaccine has been provided to Provider with no associated cost.

Identification of Dose Being Submitted

When submitting administration claims for a COVID-19 vaccine that requires multiple doses, pharmacies must submit the following information to indicate whether they are submitting an initial/restarter dose or the final dose in the regimen.

As an example, included is a section of a Payer Sheet for an initial dose. Only NCPDP Segments/Fields pertinent to special COVID-19 vaccine billing instructions are shown.

Questions? Contact your Provider Relations Representative or call Provider Services at 1-844-477-8313, Monday through Friday from 8 a.m. to 8 p.m. Eastern.

The American Medical Association published vaccine-specific CPT codes to report immunizations for COVID-19, and CMS published billing guidance (PDF) for Medicaid and CHIP providers. CMS also has published a set of toolkits to help providers swiftly administer the vaccine.

Medicaid-enrolled provider types that are eligible to provide the vaccine (must have a Medicaid ID) include: physicians, extenders, pharmacies (via pharmacists), Federally Qualified Health Centers, rural health clinics and county health departments.

All providers administering COVID vaccines must be enrolled in the federal COVID-19 vaccine program. Providers must report COVID vaccinations in SHOTS. The Pfizer vaccine is approved for ages 5 and up. The Moderna vaccine is approved for ages 18 and up. 

This list will be updated as additional vaccines become available. 

Your patients will likely have a lot of questions about the vaccine, and as their healthcare provider, they will turn to you for answers.

Q: Can I make an appointment with you to be vaccinated? If not, why? Do I have to go to a pharmacy to receive the vaccine?

A: Pharmacies are generally the most convenient locations to individuals and they also have great expertise in administering vaccines. While many providers anticipate to have the vaccine in their office later on, for now we recommend patients visit their local pharmacy. The Vaccine Finder website can help them locate the closest location with current inventory.

Q: How do we really know if COVID-19 vaccines are safe? 

A: The Food and Drug Administration (FDA) carefully reviews all safety data from clinical trials. It only authorizes emergency vaccine use when the expected vaccine benefits outweigh potential risks.

• The Advisory Committee on Immunization Practices (ACIP) reviews all safety data before recommending any COVID-19 vaccine for use.
• FDA and CDC will continue to monitor the safety of COVID-19 vaccines to make sure even very rare side effects are identified.

Q: Is the vaccine that helpful? I heard getting COVID-19 gives you better and longer immunity than the protection a vaccine can give. Can it actually make my illness worse if I do end up getting COVID-19? 

A: Explain the potential serious risk COVID-19 infection poses to them and their loved ones if they get the illness or spread it to others.

• Remind them of the potential for long-term health issues after recovery from COVID-19 disease, especially for those who have chronic conditions, are older, or have weakened immune systems.
• Explain that scientists are still learning more about the virus that causes COVID-19. And it is not known whether getting COVID-19 disease will protect everyone against getting it again, or, if it does, how long that protection might last. Therefore getting a vaccine is a safer choice.
• Some vaccines are more effective than the natural illness; it is not clear whether natural illness or vaccination will provide more effective immunity in this case.
• Early information indicates that COVID-19 vaccination may reduce the severity of illness, as well as the incidence of illness. As we learn more about the efficacy of the vaccine, we will also learn more about potential long-term protection it may bring.
• Describe how the vaccine was tested in large clinical trials and what is currently known about its safety and effectiveness.
• Be transparent that the vaccine is not a perfect fix. Patients will still need to practice other precautions like wearing a mask, social distancing, handwashing and other hygiene measures until public health officials say otherwise.

Q: I heard I need two vaccines. Why? I don’t want to come back for a second vaccine.

A: Two vaccines are needed to provide the best protection against COVID-19.

• The first vaccine primes the immune system and helps recognize the virus. The second vaccine strengthens the immune response.
• The two doses are given a few weeks apart (e.g. 21 or 28 days depending on vaccine type). Explain the dosing options available in your office and advise the patient that they can set up an appointment before they leave to come back for a second dose.
• Provide members with a vaccination record card to ensure that they know when they received their first vaccine, what type of vaccine they received and when they need to come back and receive their second vaccine.
• Direct them to their insurance health plan to set up non-emergency transportation, if applicable.

Q: What about boosters? Why do I need one and when should I get it?

A: Everyone ages 12 and older should get a booster shot after completing their primary COVID-19 vaccine series, according to the CDC. People ages 12 to 17 can only get the Pfizer booster shot. People 18 and up can get either Pfizer or Moderna. Boosters are not recommended for children younger than 12.

Q: Will the shot hurt? Can it cause me to get sick? I don’t want to get the vaccine because it will give me COVID.

A: List the most common side effects from vaccination are and how severe they may be (e.g. fever, headache, body aches, cold symptoms). Emphasize that a fever could be a potential side effect and when to seek medical care.

• Symptoms will typically go away on their own within a week. Let them know when they should seek medical care if their symptoms don’t go away.
• Explain that the vaccine cannot give someone COVID-19 as the vaccine does not contain a live coronavirus.
• Explain that side effects are a sign that the immune system is effectively working.

Q: Do I have to pay for my vaccines?

A: No. The vaccine will be at no cost to patients. They will not have to pay for either dose of the COVID-19 vaccine.

Patients look to their healthcare professionals for medical guidance and assurance. As your partners in healthcare, we want to share some tips for effectively setting expectations and addressing questions from your patients.

Start COVID-19 Vaccine Conversations Early

Even before you are able to offer COVID-19 vaccinations, consider including the topic in your conversations with patients. This will give you the opportunity to set expectations about vaccine availability, including if/when you might recommend vaccination for them, and learn about any concerns they have.

Engage in Effective COVID-19 Vaccine Conversations

Effective engagement can occur during an in-person office visit, through messages on your patient portal, or at a telemedicine appointment. Patients trust in their providers to help guide healthcare decisions, and your strong vaccine recommendation is the most important part of the conversation.

Start with empathy and understanding.

• Acknowledge the disruption COVID-19 has caused in all our lives.
• Provide an opportunity to recognize common concerns that can be addressed by a vaccine.

Assume patients will want to be vaccinated but may not know when to expect it.

• Consider providing the following general information to patients about the timeline for COVID-19 vaccines:
  • Limited COVID-19 vaccine doses may be available in 2020.
  • It is anticipated that vaccine supply will increase substantially in 2021.
  • The goal is for everyone to be able to easily get a COVID-19 vaccine as soon as large quantities are available. However, not everyone will be able to get vaccinated right away.
• Encourage patients to continue taking steps to protect themselves from COVID-19 and let them know how you plan to share updates about vaccine availability.

Give your strong recommendation.

• Let your patients know if you plan to recommend COVID-19 vaccination for them.
• Share the importance of COVID-19 vaccines to protect patients’ health as well as the health of those around them.
• Talk about your personal plans to get a COVID-19 vaccine.
• Reassure your patients that the vaccine is safe.

Listen and respond to questions.

• If a patient has concerns or questions, this doesn’t mean they won’t accept a COVID-19 vaccine. Sometimes patients want your answers to their questions.
• Your willingness to listen to their concerns will play a major role in building trust in you and your recommendation. Make it clear that you understand they have questions, and that you want to answer them, so they feel confident in choosing to get vaccinated.
• Seek to understand patient/caregiver concerns and provide information they need in a way they can understand it.

Keep the conversation open.

• After answering their questions, let your patients know that you are open to continuing the conversation and answering any additional questions they may have.
• Encourage patients to take at least one action like:
  • Scheduling another appointment.
  • Reading any additional information you provide them about COVID-19 vaccination.
  • Encourage others to get their COVID-19 vaccine when available.
• Continue to remind patients about the importance of getting a COVID-19 vaccine during future routine visits.

• The Centers for Disease Control (CDC)
• National Institutes of Health (NIH)
• The Centers for Medicare and Medicaid (CMS)
• The American Medical Association (AMA)