2008 PDE Part D Vaccine Administration Guidance

In 2008, Medicare Part D will include coverage of fees for the administration of Part D vaccines. Part D sponsors will be responsible for reporting these fees to CMS on their prescription drug events (PDEs). The following guidance is intended to clarify the information Part D sponsors should provide in specific PDE fields with respect to Part D vaccine administration fees. The guidance addresses in and out-of-network scenarios in which the Part D vaccine and administration fee are submitted to the Part D Sponsor on one claim (1 PDE) and scenarios in which the Part D vaccine and Part D vaccine administration fee are submitted to the Part D sponsor on separate claims (2 PDEs). Current PDE guidelines apply to all fields that are not specifically identified in this document.

In addition to a new Vaccine Administration field, several new edits will be created and several PDE edit errors will be modified to accommodate the inclusion of vaccine administration as part of total drug cost.

PDE Fields

Field 8: Date of Service

The date of service is the date the Part D vaccine was dispensed if one PDE is being submitted for both the Part D vaccine and administration fee (regardless of the date of administration). If the Part D vaccine and administration fee are submitted on separate PDEs, then the date of service on the PDE with the Part D vaccine only is the date the vaccine was dispensed and the date of service on the PDE with the Part D vaccine administration fee only is the date the vaccine was administered.

Field 10: Rx Service Reference Number

The Rx Service Reference Number is the pharmacy issued numeric code that identifies a dispensed prescription. In cases where this code was not submitted by a pharmacy on the claim (e.g. out-of-network claims for Part D vaccine administration fees or Part D vaccines plus administration fee), the plan must assign a unique number for any date of service and service provider ID combination. This is consistent with the current PDE guidance for all out-of-network claims for Part D drugs.

Field 12: Product Service ID

The product service ID is the NDC for the Part D vaccine and must be identified on all PDEs submitted for Part D vaccines only, Part D vaccine administration fees only, or both.

Field 15: Fill Number

The fill number on PDEs for all in-network claims for Part D vaccines only or Part D vaccines plus administration fees is completed in the same manner as it is for all Part D drugs. The fill number is always zero for out-of-network claims for the Part D vaccine only, the Part D vaccine administration fee only, or both.

Field 23: Drug Coverage Status

The drug coverage status is C=3Dcovered on all PDEs submitted for Part D vaccines only, Part D vaccine administration fees only, or both.

Field 28: Ingredient Cost

The ingredient cost is the cost of the Part D vaccine on all PDEs for Part D vaccines only or Part D vaccines plus administration fees. The ingredient cost field should be zero for all PDEs for the Part D vaccine administration fee only.

Field 29: Dispensing Fee

The dispensing fee field should be zero on all PDEs for Part D vaccine administration fees only and all PDEs for Part D drugs (including Part D vaccines) not dispensed from a pharmacy.

Field 33: Patient Pay Amount

The patient pay amount is the co-pay or coinsurance on PDEs for Part D vaccines only, Part D vaccine administration fees only, and Part D vaccines plus administration fee. The patient pay amount field should be zero on PDEs for Part D vaccine administration fees only if a separate co-pay was not charged on the vaccine administration only claim.

Field 40: Vaccine Administration Fee

The Part D vaccine administration fee is submitted on PDEs for Part D vaccine administration fees only or Part D vaccines plus administration fee. The Part D vaccine administration fee field should be zero on PDEs for Part D vaccines only.

NEW PDE Edits

Edit 647

Reject edit if Field 40 is populated with an amount greater than zero on PDEs with service dates prior to January 1, 2008 or Field 40 is populated with invalid data.

“Vaccine Administration Fee Amount is missing or invalid. For service dates effective January 1, 2008 forward, must be >=3D zero. For service dates prior to 2008, must be zero or spaces.”

Edit 694

Reject edit if the sum of the (Ingredient Cost + Dispensing Fee + Vaccine Administration Fee) is less than or equal to zero.

“The sum of Ingredient Cost, Dispensing Fee, and Vaccine Administration Fee must be > zero.”

Edit 763

Reject edit if Field 40 is populated with an amount greater than zero and Field 23 (Drug Status Code) is populated with ‘E’ or ‘O’.

“If Drug Coverage Status Code is ‘E’ or ‘O’ then the Vaccine Administration Fee must be zero.”

Edit 742

Reject edit if Field 40 is populated with an amount greater than zero and field 12 (Product Service ID) is populated with an NDC which is not a vaccine.

“If the amount in the Vaccine Administration Fee field is >0, then the NDC code must qualify as a valid Part D vaccine drug.”

MODIFIED PDE Edit Logic

Edit 641

Positions 299-306 of the PDE layout no longer considered FILLER.