Medicare requires that all Medicare Advantage plans process vaccines in accordance to the benefit coverage type Medicare has deemed appropriate.
Medicare has determined that most vaccines (and the associated administration fee) are to be covered under the Medicare prescription drug benefit, Part D. The process is as follows:
- The physician may require the patient to pay up front for the Part D vaccination and the administration fee.
- The physician office can bill for the Part D vaccination through our medical claims system. The claim will reject for "Covered under Part D Pharmacy" but will be reviewed and processed by Independent Health’s pharmacy department.
- Part D vaccinations and administration fees will not be reimbursed through the medical claims system. They must be paid under Part D as the vaccination and administration fee counts towards the members True Out-of Pocket (TROOP).
- The reimbursement will be sent to the member based on our fee schedule.
- If the member did not pay up front, they will be responsible for forwarding the check to the physician office.
- If the physician office is unable to bill through our medical claims system, provide the member with the one of the following:
- The member would then submit either item to Independent Health for reimbursement up to the allowed amount on the fee schedule.
There are exceptions where some vaccinations (and the associated administration fee) should be billed under Part B, Medicare’s medical benefit. Payment for Part B vaccinations will be made to the provider. Providers should follow the following claim submitting process:
- If a vaccination is administered due to injury in a provider office or urgent/emergency care, the Part D vaccine would be covered under Part B. This instance would be found in the physician’s notes, and it is the only case where Part D vaccines and administration fees would be covered under Part B.
- The provider would submit the claim under Part B. Any vaccination claim that has a diagnosis code or place of service as urgent or emergent will pay under Part B to the provider.
Also, please note these other important reminders:
- Payment for Part D vaccinations will be made to the member because currently Independent Health’s pharmacy claims system is unable to pay medical providers. Providers may bill members for the administration fee directly if they did not provide payment at the time of service.
- Independent Health will only reimburse up to the fee schedule. Learn more.
- Participating providers are not allowed to bill over the fee schedule, and members cannot be held responsible for amounts over the fee schedule.
If you have questions, please contact our Provider Relations Department at (716) 631-3282 or 1-800-736-5771, Monday through Friday from 8 a.m. to 6 p.m.