Anyone know how to properly bill insurance for vaccines?

[Notcow]

This question is particularly in regard to Medicaid and Medicare billings. Even more specifically, AHCP. I'm a Pharm Tech at a CVS is a pretty poor district, so ~75% of our patients are now Medicaid, and they don't play nice with vaccines for some reason. Despite this, practically every state's Medicaid program bar Florida fully covers the flu vaccine.

It looks like adjudication would require "CPT codes"...which I've never heard of and don't know how to get to that field.

I assumed that every store had to deal with a large influx of Medicaid patients due to the recent shakeup, but apparently not since no one in my district seems to know how to bill them.

Billing insurance via the standard method usually soft-rejects, advising me to enter "MA" in the Professional Service Code field. They will then proceed to reject anyways indicating that there's an invalid code in our Professional Service Code field.

Hilariously, I've been advised by the brass to use the 72-hour overrides, but until I get that in writing I'm not doing it.


Any links to resources would be appreciated.

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[ornithoptor]

Hi, I would imagine that CVS should be able to provide you with some information, after all, you are working hard making them profit.
Man, this is a huge topic, I am not sure where I can start, I deal mostly under IP and OP setting. Medicare is easier, for OP, you have J code, perhaps setting up use rostering billing at IP. In ambulatory setting, Medicaid can be tricky since you have to not only use CPT code, you may have to bill with proper multiplier and especially modifiers. Of course, we also deal with free vaccines from the state. You are not in position nor your job to fight this alone. I strongly urge you to ask your manager to send you to neighbor store to observe the proper steps. Information from forum may not be applicable to you.
Good luck.


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[ornithoptor]

BTW, Hippa space is free, but Vitalware has tons of valuable information will likely cost you.


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[Notcow]

The thing is, a large majority of that stuff is handled automatically by RxConnect, and to a high degree of accuracy as well. When someone bills a vaccination to Medicare B, it doesn't actually prompt us to enter things like CPT codes, and for the codes it does require use to input the software generally does a good job of letting us know (upon rejection) which required code fields are required/invalid, and also through finding a solution. This is a rare exception where there's no corrective suggestions, and the information which is not being handled, or handled incorrectly via automation, isn't easily identifiable.

As an aside, that's a nice perfect world solution, but we as a store are expected to deal with this alone. My superiors/pharmacy phone support haven't been able to offer valid solutions, and if we can't find a solution on our own the brass are perfectly happy to just penalize underpreforming stores until the problem is solved or expires as an issue. Sorry if that sounds rant-y, but...welcome to CVS.

Any further guidance which involves where to put codes would be appreciated.

 

[ornithoptor]

I sympathize with your situation. With more information, I am in better position to offer assistance, and CVS should appreciate your efforts outside of the work.
After hearing your situation, I have one final option that will work in your case. You can first reach out to your product vendor reps, they will connect you to reimbursement expert on their products, and will provide helps to guide you on filing. You have among GSK, Merck, and Senofi. Unless Prevnar, which is Pfizer. If you can't make the connection, go to product website, which usually have reimbursement contacts for you. BTW, you should be recognized for your hard work. I would assume most people would nit care.


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