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Elizabeth M. Whitehorn, Director

Provider Notice issued 10/24/12

Influenza Vaccine Administration Fee Billing Requirements

To:​ Participating Pharmacies​
​Date: ​October 24, 2012
​Re: Influenza Vaccine Administration Fee Billing Requirements​

The purpose of this notice is to inform pharmacies of the proper billing requirements for the influenza vaccine administration fee. Effective with the 2012- 2013 flu season, pharmacies must bill the influenza vaccine administration fee as a separate transmission using the NCPDP D.0 S1 transaction. The chart included with this notice identifies the specific fields and values that are required on the claims. For additional information, please refer to the NCPDP D.0 Companion Guide and Payer Sheets available on the 5010 Companion Guide Web page.

 

Any questions regarding this notice should be directed to the Bureau of Pharmacy Services at 877-782-5565, Option 7.

 

Theresa A. Eagleson, Administrator
Division of Medical Programs

 

Flu Vaccine Billing

B1 Record (Claim Billing):

Transaction Header:

Field No. Field Name Value Description
401-D1 Date of Service   Date Prescription was filled (CCYYMMDD)
AM 07 Claim Segment:    
455-EM Prescription/Service Reference Number Qualifier 1 Prescription Billing
402-D2 Prescription/Service Reference Number   12 byte Prescription Number
436-E1 Product/Service ID Qualifier 03 NDC
407-D7 Product/Service ID   11 byte NDC

S1 Record (Service Billing):

AM 07 – Claim Segment:

 

Field No. Field Name Value Description
455-EM Prescription/Service Reference Number Qualifier 2 Service Billing
402-D2 Prescription/Service Reference Number   12 byte Service Reference Number
436-E1 Product/Service ID Qualifier 06 DUR/PPS (Professional Pharmacy Service)
407-D7 Product/Service ID   11 zeroes (00000000000)
456-EN Associated Prescription/Service Reference No.   12 byte Prescription Number in B1 record 402-D2
457-EP Associated Prescription/Service Date   See Date of Service (401-D1) in B1 Transaction Header
453-EJ Originally Prescribed Product/Service ID Qualifier 03 See 436-E1 in B1 record
445-EA Originally Prescribed Product/Service Code   Same as 11 byte NDC (407-D7) in B1 record

 

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