Without question, vaccine claims are on the rise! Consequently, PAAS National® analysts have recently seen an increased number of PBM audits for these claims. Consider a few best practices to reduce your risk of audit recoupments:
Quantity – Submit the correct NCPDP billing unit of each (EA) or milliliter (mL) based on vaccine product
Day Supply – NCPDP recommends that all vaccine claims be submitted as a 1-day supply
- Submit the origin code in accordance with how you received the prescription
- 1 – written, prescription obtained via paper.
- 2 – telephone, prescription obtained via oral instructions or interactive voice response using a phone.
- 3 – electronic, prescription obtained via SCRIPT or HL7 Standard transactions, or electronically within closed systems.
- 4 – facsimile, prescription obtained via transmission use a fax machine.
- 5 – pharmacy, this value is used to cover any situation where a new Rx number needs to be created from an existing valid prescription such as traditional transfers, intrachain transfers, file buys, software upgrades/migrations, and any reason necessary to “give it a new number. This value is also the appropriate value for “Pharmacy dispensing” when applicable such as BTC (behind the counter), Plan B, established protocols, pharmacists’ authority to prescribe, etc.
- Note that codes 1-4 represent patient-specific prescriptions while code 5 covers various other situations
- Submit the NPI of the prescriber
- This would be the prescriber of a patient-specific prescription or standing protocol
- This would be the pharmacist Type 1 NPI (individual) as per state law where pharmacists have prescribing authority or when ordered under PREP Act declaration during COVID-19 pandemic
|Item||Comments||Requested in audits|
|Authority to Administer
|Screening Checklist||Not requested by PBMs, however should retain for your records||No|
|Vaccine Administration Record (VAR)||Must document every administration (required by law)
Include at least the following:
|VIS or EUA Fact Sheet||Most current version must be provided prior to each administration (required by law)||No|
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