Submitting information for TRICARE vaccines in order to get paid appropriately is a source of difficulty for many practices. No matter who does your billing, having a full understanding of how this works is important for all practices that administer vaccines to patients covered by TRICARE insurance. In addition, it is important to realize the following: just because you got paid, doesn’t mean you did it appropriately.
What does this mean? There are practices that have submitted 1 mL when a vaccine is really only administered at 0.5 mL volume. They were inappropriately paid double what they should have been. TRICARE often discovers their mistake a year or more later and takes back all of the overpayment. Similarly, there are practices that only got paid a portion of what they were supposed to be paid (Rotavirus is a good example) and they were not covering their costs and continuing to do business as usual. They are owed additional payments from TRICARE, and if timely filing has not passed, should consider submitting a corrected claim to be made whole.
Note: Rotarix and Rotateq are billed differently as are Menactra and Menveo.
Note: This is not appropriate information for Washington state, which is a universal purchasing vaccine state.
Set Up Vaccine Tables with NDC and Unit of Measure (UOM)
Click here to view OP's Claims Filing Tips. This will walk you through the tables that OP pulls vaccine information from for claims.
How to Create a Claim and How it Should Look
For information on how to convert superbills, click here.
Review Your Claims
As a final check, it may be helpful to look at your 837 EDI files (electronic claims transmission files) to see that you are actually sending what you think you’re sending.
We’ve become aware that some practices THINK they may be sending a certain NDC number or NDC UOM, but they are actually sending something different, and/or they have not appropriately set up their vaccine tables.
Also, note that if you are sending paper claims, TRICARE has different requirements.
For electronic claims: TRICARE wants most vaccine NDCs to have a 1 UN NDC UOM, but a few vaccine NDCs should have a 0.5 ML NDC UOM. Vaccine claims should look something like this:
- Yellow = CPT code (90734, here Menactra)
- Black = Kressly Pediatrics' charge (obfuscated for anti-trust purposes)
- Blue = Date of service (2016/01/06, January 5, 2016)
- Pink = 11-digit NDC number (notice the N4 prefix)
- Green = NDC UOM (.5 and ML, separated by asterisk *
So, when we say “0.5 ML” NDC UOM, we mean that the last part of your vaccine charge (the segment that starts with CTP**) should go out looking like this:
Or, the CTP segment might have a leading zero:
When we say “1 UN” NDC UOM, we mean that the claim should look like this:
Note that BOTH the 0.5 ML NDC UOM claims and the 1 UN NDC UOM claim all have UN*1 in the top of the line item (yellow highlight). That’s number of billed units (like if you do two 96110, you bill 2 units of it) which is different than the NDC UOM (pink highlight).
Which vaccines should be billed which way?
Short rule: Vaccines that are in a ready-to-administer vial or syringe should be billed according to their volume (usually 0.5 ML). Vaccines that are reconstituted from components (such as MMR from diluent or the two vials of Pentacel) should be billed as 1 UN.
As best we can tell, TRICARE pays vaccines according to the contracted rate if the following vaccines are submitted as follows:
|1 UN NDC UOM||0.5 ML NDC UOM||Either one seems to work||Special (see below)|
|90468 (Hib - ActHib, Hiberix)||90633 (Hep A)||90670 (Prevanr 13)||90680 (Rotateq)|
|90698 (DTaP/IPV/Hib "Pentacel)||90651 (Gardasil)||90744 (Hep B)|
|90707 (MMR)||90700 (DTaP)||90715 (Tdap)|
|90716 (Varicella)||90713 (IPV)||All flu vaccines|
|90734 (Menveo)||90734 (Menactra)|
|90681 (Rotarix)||90723 (DTaP/IPV/Hep B "Pediarix)|
|90710 (MMRV)||90620 (Men B "Bexsero")|
|90621 (Men B "Trumemba")|
|90696 (DTaP/IPV "Kinrix, Quadracel")|
Rotateq vaccine is an exception:
It will pay properly using the NDC UOM “2 ML”.