Pharmacies can qualify for direct payments for immunizations

We’d like to remind pharmacy providers that they can be directly reimbursed for administering certain vaccines as a participating pharmacy under our medical and surgical benefits.

How does this work?
As you read in the November Record, covered professional services qualify for reimbursement through Blue Cross Blue Shield of Michigan medical and surgical benefits — not under the pharmacy benefit — as long as the member has immunization coverage. Pharmacies must bill for vaccines and their administration on either the paper CMS-1500 claim or the 837 electronic CMS-1500 claim for BCBSM. Please see the September 2013 Record for direction on how to submit the national drug code and quantity on your claim.

Which pharmacies are eligible?
Each pharmacy must first be credentialed and approved to participate in the BCBSM pharmacy network before being eligible for reimbursement through the vaccine pharmacy network for professional medical and surgical benefit plan claims. Participating pharmacies that subsequently sign the vaccine network contracts will receive new Blues professional provider identification numbers. This will allow professional eligibility verification access through web-DENIS. Each pharmacy must use its national provider identifier number for billing these professional services.

If your pharmacy participates in our vaccine pharmacy network, we’ll send payments for covered professional services directly to your pharmacy. For consistent provider payment procedures, the Blues will allow pharmacies to designate other entities as payees.

To be eligible for reimbursement, pharmacies must meet the Blues qualification and reimbursement standards outlined in the Vaccine Affiliation Agreement.

A qualified pharmacy that wants to become eligible for direct reimbursement as a participating provider can apply for a Blues professional PIN by following these steps:

1. Become credentialed and approved as a participating BCBSM pharmacy.
   
   
2. Visit the Enrollment and Changes Web page at bcbsm.com/provider/enrollment.

• Under the Enrollment and Changes banner, click on Physicians and Professionals.
• Click on Next.
• Select Enroll a new provider.
• Click on Next.
• Select Vaccine Pharmacy.
• Click on Next, then follow the instructions to apply.

3. Complete the required immunization administration training. The Michigan Pharmacists Association offers a program. You may contact them at michiganpharmacists.org.**

Note: The pharmacy must register all immunizations with the Michigan Care Improvement Registry.

Submitting the NDC on claims
Here are some quick tips and general guidelines to assist you with proper submission of valid NDCs and related information on professional claims:

• The NDC must be submitted along with the applicable Healthcare Common Procedure Coding System or Current Procedural Terminology code.
• The NDC must follow the “5digit4digit2digit” format (11 numeric characters with no spaces or special characters). If the NDC on the package label is fewer than 11 digits, you must add leading zeroes to total 11 digits.
• The NDC must be active for the date of service.
• To submit electronic claims (ANSI 837P), report the following information:

• To submit paper claims, enter the NDC information in field 24 of the CMS-1500 claim. In the shaded portion of field 24A-24G, enter the qualifier “N4” left-justified, immediately followed by the national drug code. Next, enter the appropriate qualifier for the correct dispensing unit (GR, UN, ML or ME), followed by the quantity and the price per unit, as indicated in the example below.
• The format for billing should be:
  N4 + NDC code + 3 spaces+ unit of measure + quantity
  Example: N4555103026710 ML5.5

For BCN, please see previous notification on how to bill effectively.

Which members are covered?
This program applies to BCBSM commercial (non-Medicare) members with Traditional or PPO coverage, excluding Federal Employee Program members. Member benefits will vary by group for immunization coverage. The pharmacy should check eligibility through web-DENIS.

Vaccine code list
Blue Cross will pay eligible pharmacies directly for the following procedure codes for the vaccines and the administration services listed below.

Note: Vaccines will be paid at either 100 percent of the standard BCBSM fee schedule or the pharmacy’s retail charge (whichever is less), minus applicable member copayments and deductibles. Administration of vaccines will be paid at 85 percent of the standard Blues fee schedule or the pharmacy’s retail charge (whichever is less), minus applicable member copays and deductibles.

The retail charge is the pharmacy’s charge per vaccine to its cash-paying customers notwithstanding the billing terminology associated with such charge. In addition, any retail charge specific to certain demographic groups will also be given to BCBSM for similar members.

Additional codes, new vaccines
The following administration codes may apply: G0008, G0009, *90471, *90472, *90473 and *90474. The vaccine codes that were initially included in the program were *90655, *90656, *90657, *90658, *90660, *90663, *90732 and *90736. We will be including the following additional influenza vaccine codes: *90654, *90661, *90662, *90672, *90686, *90688, Q2034, Q2035, Q2036, Q2037 and Q2038 in the program. There are several new vaccines that will be now included in the program, effective April 1, 2015, as follows:

For more information, see the appropriate BCBSM payment schedules on web-DENIS.

**Blue Cross Blue Shield of Michigan and Blue Care Network do not control this website or endorse its general content.