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Elizabeth M. Whitehorn, Director

Provider Notice Issued 01/12/2022

Date:    January 12, 2022

To:       Enrolled Pharmacies

Re:      Pharmacy Instructions for COVID-19 Vaccine for Children Ages 5-11

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 This notice informs providers that children ages 5-11 can now receive two 10mcg doses of Pfizer COVID-19 vaccine.

The Illinois Department of Healthcare and Family Services will reimburse Medicaid participating pharmacies an administration fee through NCPDP claim submission for all federally allocated COVID-19 vaccines. The specific instructions below apply to Medicaid fee-for-service claims, but the Medicaid managed care plans will also reimburse these claims through NCPDP claim submission.

Pharmacies may bill claims with dates of service beginning November 2, 2021 for the children's dose and administration via an electronic NCPDP claim according to the following instructions:

  • Submit each vaccine with the specific approved vaccine NDC for an eligible participant.
  • Submit claim with a Basis of Cost Determination (423-DN) of "15" (Free product or no associated cost) with an associated Ingredient Cost Submitted (409-D9) value of $0.00.
  • Submit claim with the Professional Service Code (440-E5), populated with an "MA" (Medication Administered) to identify that the product was administered.
  • Quantity Dispensed (442-D7) should be submitted with the value that represents the quantity of drug product administered. 
  • Days Supply (405-D5) should be submitted with a value of "1".
  • Vaccines must be administered according to approved labeling for appropriate ages and dosing interval.
  • Submit the vaccine administration fee listed below in the Incentive Amount Submitted field (438-E3) on the same claim as the vaccine (i.e., ingredient). 

 

NCPDP Codes and Allowed Amounts for COVID-19 Vaccine Administration

Dose Submission Clarification Code
(420-DK)		 Incentive Amount (Administration Fee 438-E3) Ingredient Cost
(409-D9)
Multi-Dose Vaccines      
First Dose 02 $42.14 $0.00
Second Dose 06 $42.14 $0.00


The payment rate for a COVID-19 vaccine administration requiring a series of two or more doses is $42.14 for each dose in the series.

  • For multi-dose vaccines, submit 02 (other override) for the initial dose in the SCC field.
  • For the second dose, submit 06 (the previous medication was a starter dose and now additional medication is needed to continue treatment) in the SCC field.
  • Pharmacies must enter the NPI of the prescriber in the Prescribing Practitioner (411-DB). If the prescriber is the pharmacist, the NPI of the pharmacist may be submitted. If the pharmacy is using a pharmacist NPI, the pharmacy must submit a Submission Clarification Code (SCC) of "42" and Prescription Origin Code (419-DJ) would be "5 "– Pharmacy.

 

Vaccine administration for the uninsured should be billed through the federal
HRSA COVID-19 Claims Reimbursement Portal.

Pharmacy providers with questions regarding fee-for-service program vaccine administration may call the Bureau of Professional and Ancillary Services at
877-782-5565. Pharmacies billing via NCPDP for HealthChoice Illinois managed care members should contact the applicable managed care plan.

 
Kelly Cunningham, Administrator
Division of Medical Programs