CurrentEmblemHealthPolicy RPC20220032

Part D Vaccine Billing Guidelines (Medicare)

Defines billing and reimbursement rules for Medicare Part D vaccines (ACIP-recommended vaccines not covered under Part B) and explains how providers and pharmacies should submit claims; affects physicians, pharmacists, and other health care professionals administering vaccines to Medicare patients.

Policy Summary

PayerEmblemHealth

PolicyPart D Vaccine Billing Guidelines (Medicare)

Policy CodePolicy RPC20220032

Change TypeIncludes ACIP vaccinesRSV added

Effective DateMay 16, 2023

Next Review DateN/A

Key ActionPhysicians may submit Part D vaccine claims electronically through TransactRx for direct payment; registration required.

SourceLink

POLICY UPDATE CHANGES

Policy updated to include RSV Vaccines (Part D).

Policy updated to include/reference Advisory Committee on Immunization Practices (ACIP) vaccines.

Transferred policy content to individual company-branded template; no changes to title or number.

Policy updated to include EmblemHealth Medicare Advantage Plans effective 5/16/2023.

ACIP vaccinesPart D must cover

4 examplesPart B-covered vaccines listed

TransactRxElectronic claims portal

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Vaccine Coverage and Billing Principles

Vaccine coverage

Covered when ALL of the following are met:

Part D plans must cover all Advisory Committee on Immunization Practices (ACIP)–recommended vaccines that are not covered under Medicare Part B.

Examples of vaccines classified as Part D include RSV, MMR, meningitis, shingles, and Tdap.

Examples of vaccines classified as Part B (not covered under Part D) include influenza, COVID-19, hepatitis B, and pneumococcal.

Billing channels

Billing responsibilities and permissible channels:

ONE of

Physicians may submit Part D vaccine claims electronically through TransactRx for direct payment (registration required).

ONE of

Providers may direct patients to in-network pharmacies to have the pharmacist administer Part D vaccines; the pharmacy bills the Part D plan for the vaccine and administration when applicable.

ONE of

Pharmacies may fill and ship Part D vaccines to physician offices (or patient picks up and brings to physician); pharmacy bills Part D for the vaccine product and the physician bills Part D for administration only.

Denial risk

Denials and coding compliance guidance:

EmblemHealth will not reimburse claims for Part D vaccines administered in the physician's office if those services are submitted under the Part B medical benefit.

If appropriate coding/billing guidelines or current reimbursement policies are not followed, EmblemHealth may deny the claim and/or recoup claim payment.

Follow industry coding edits and sources (CPT guidelines, specialty organizations, CMS including NCCI and MUE) and use industry-standard claims editing software to ensure compliance and reduce denial risk.

Coding and Edit Sources

Coding guidancemixed

Policy references adherence to CPT, CMS, NCCI, MUE and industry coding edits; specific billing codes not listed in this document.

Vaccine categorization (Part D examples)CPTCovered

	Respiratory Syncytial Virus Disease (RSV)
	Measles, Mumps and Rubella (MMR)
	Meningitis
	Shingles
	Tdap (tetanus, diphtheria, pertussis)
	Note: Part D plans must cover all ACIP-recommended vaccines not covered under Part B; Part B covers Influenza, COVID-19, Hepatitis B, and Pneumococcal.

Coding edit sources

Coding edit sourcesApply CPT guidelines from the American Medical Association, CMS edits (including NCCI and MUE), specialty organization edits, and industry-standard claims editing software when adjudicating vaccine claims; conflicts between sources will be resolved by applying the edits deemed appropriate by EmblemHealth.

Software useUse industry-standard claims editing software products to implement coding edits and adjudication rules for vaccine billing.

Conflict resolutionWhen coding source conflicts arise, EmblemHealth will apply the edits it determines are appropriate and can provide explanations upon request.

Denial/recoupment riskIf appropriate coding/billing guidelines or current reimbursement policies are not followed, the claim may be denied and/or payment may be recouped.

Scope of sourcesEdits are based on industry sources including CPT, CMS (NCCI, MUE), and specialty organizations; the list is not limited to these sources.

Provider and Pharmacy Billing Actions

Billing Rule

Submit Part D vaccine claims via TransactRx (registration required)

If you wish to continue administering Part D vaccines in your office, register for and submit claims electronically through TransactRx so payments for submitted Part D vaccine claims are sent directly to you (TransactRx registration is free).

TransactRx sends payments directly to the physician twice a month.
TransactRx can help minimize patients' upfront out-of-pocket costs.
Registration details: http://www.transactrx.com/physician-vaccine-billing

Billing Rule

Refer patients to in-network pharmacy for administration (pharmacy bills Part D)

Direct patients to an in-network retail pharmacy to have the pharmacist administer Part D vaccines; the pharmacy will bill the Part D plan for the vaccine.

Definitions and Examples

Part D vaccines — definition and examples

DefinitionPart D vaccines are all ACIP-recommended vaccines that are not covered under Medicare Part B.

Examples of Part D vaccinesRespiratory Syncytial Virus (RSV), Measles-Mumps-Rubella (MMR), Meningitis, Shingles, Tdap.

Part B-covered vaccines (not Part D)Influenza, COVID-19, Hepatitis B, Pneumococcal.

Coverage requirementPart D plans must cover all ACIP-recommended vaccines not covered under Part B, per CMS guidance.

Policy Revision History

2025-12-02template_transfer

Policy content transferred to individual company-branded template; no changes to policy title or number.

2023-10material_update

Policy updated to include RSV vaccines (Part D) and to reference Advisory Committee on Immunization Practices (ACIP) vaccines.

2023-01coverage_expansion

Policy updated to include EmblemHealth Medicare Advantage Plans, effective 2023-05-16.