NCPDP Modified Section 11.15 of the Emergency Preparedness Guidance Document – COVID-19 Oral Antivirals Billing

• Like the COVID-19 vaccines, oral therapeutics are currently purchased by the federal/state government and must be dispensed with no cost to the patient
• Before a pharmacist prescribes an oral antiviral to treat COVID-19 under the EUA, they must make an assessment and determine if the patient meets the criteria
• When billing a claim for a no-cost product, the claim request uses standard fields with applicable pricing and professional service identifiers
• Section 11.15.1 is now titled Free Product Dispensing with Unique Dispensing Requirements, (e.g., patient education/counseling for the Dispensed Medication)
  • Added diagnosis code and prescriber ID bullets
  • Professional service code – removed “AS” and modified the “PE” description – (Patient Education (PE) should be submitted on the claim to identify the unique dispensing requirements)
  • Modified the incentive amount submitted descriptions
  • Updated the example table
    • Added insurance segment, origin code segment, and prescriber segment
    • Changed the DUR/PPS segment professional service code value to PE – patient education
    • Added an entire claim response to the example
  • To help standardize how these claims are processed, NCPDP recommends billing separate claims for the following:
    • Product dispensing (B1 claim) See section 11.15.1 for correct claims processing
    • Patient assessment (S1 or B1 with the 11-digit EUA patient assessment product/service ID)
      • Once an assessment is complete, it could be determined the patient does not meet the criteria – pharmacy should bill a patient assessment only claim – see link to section 11.16 below
    • If a completed assessment results in the product being prescribed, the pharmacy may need to submit the claim for the patient assessment to one payer and the claim for the product to another payer
  • Inserted new section 11.16, Billing of Patient Assessment, Professional Services Associated to EUA COVID-19 Oral Antiviral Pharmacist Prescriptive Authority

Review February 2022 Newsline, COVID-19 Oral Therapeutics Antiviral Billing Guidance for more information on billing guidance from NCPDP