CurrentHealthfirstPolicy N/A

Pharmacist COVID-19 Vaccine Counseling Reimbursement

Rules and billing instructions governing reimbursement to pharmacists for providing COVID-19 vaccine counseling to eligible New York State Medicaid members; affects pharmacies and pharmacists submitting claims in NYS.

Policy Summary

PayerHealthfirst

PolicyPharmacist COVID-19 Vaccine Counseling Reimbursement

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionBill counseling using NCPDP D.1 fields: submit Professional Service Code 'PE' in 440-ES and populate Incentive Amount Submitted (438-E3) at least equal to the expected administration fee.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

one-timemaximum counseling reimbursements allowed

8 minrequired counseling duration

NCPDP D.1required claim format

PENCPDP code for counseling/education

Billing Eligibility and Criteria for Counseling

Billing criteria for COVID-19 vaccine counseling

Policy Summary

PayerHealthfirst

PolicyPharmacist COVID-19 Vaccine Counseling Reimbursement

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionBill counseling using NCPDP D.1 fields: submit Professional Service Code 'PE' in 440-ES and populate Incentive Amount Submitted (438-E3) at least equal to the expected administration fee.

SourceLink

On This Page

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.

Billing criteria for COVID-19 vaccine counseling

ALL of the following

Member is unvaccinated (has not received an initial/first dose of a COVID-19 vaccine).
Refer to NYSDOH guidance
Member does not have an appointment scheduled to receive an initial/first dose.
Reimbursement allowed only once per unvaccinated member; counseling on second and subsequent doses is not billable.
If vaccination is medically contraindicated, the counseling session is not billable.

Documentation required

Session documented in the medical or pharmacy record.
Documentation confirms patient is unvaccinated (no initial/first dose).
Documentation confirms patient does not have an appointment scheduled for an initial/first dose.
Confirm parental/guardian/caregiver consent to receive counseling, if appropriate.
Confirm vaccination status in the New York State Immunization Information System (NYSIIS) whenever possible.
Strong recommendation of COVID-19 vaccination (unless medically contraindicated).
Counseling on safety and effectiveness of COVID-19 vaccines and answering patient/parent/guardian/caregiver questions.
Counseling session duration: minimum eight minutes.
Arrange for vaccination or provide information on how the patient can get vaccinated for COVID-19.

Attestation option: If pharmacy software is limited, pharmacist may provide an attestation that the above actions have been met (e.g., 'Meets NYS DOH Counseling Criteria for COVID-19 Vaccination').

Use only when software limits documentation in system; still must meet all other criteria.

Required NCPDP Fields and Coding Instructions

Required NCPDP fields for counseling/admin claimsNCPDPCovered

440-ES=PE	Professional Service Code: Patient Education (counseling)
438-E3=Administration fee amount (>= expected)	Incentive Amount Submitted — include amount equal to or greater than expected administration fee
409-D9=ZS0.01 or $0.01	Ingredient Cost Submitted — submit ZS0.01 when government-supplied vaccine (example value shown)
423-DN=15	Basis of Cost Determination — Free product / no associated cost (Basis of Cost Determination = 15)

Incentive Amount Submitted minimum

RuleIncentive Amount Submitted (NCPDP field 438-E3) must be equal to or greater than the expected administration fee.

Reimbursement impactIf the submitted Incentive Amount is less than the applicable administration fee, reimbursement will be less than the maximum possible applicable administration fee.

Where to send the valuePopulate Incentive Amount Submitted (438-E3) in the Pricing Segment when submitting counseling/administration claims.

Professional Service Code requirementSubmit Professional Service Code 'PE' in 440-ES when billing counseling with administration; do not submit 'MA' for combined administration and counseling.

Provider Billing Rules and Authorization

Note

Eligibility and general authorization

Pharmacists may request reimbursement for one counseling session per unvaccinated member (only for individuals who have not received an initial/first dose and do not have an appointment for an initial/first dose). Counseling on second or subsequent doses is not billable. Counseling must be documented in the pharmacy or medical record and meet NYSDOH criteria (see documentation requirements). If pharmacy software cannot capture required fields, a pharmacist attestation stating "Meets NYS DOH Counseling Criteria for COVID-19 Vaccination" may be used.

Limit: one counseling reimbursement per unvaccinated member (initial/first dose only).
Counseling session must be documented and include: confirmation of unvaccinated status; confirmation no appointment for initial/first dose; consent of parent/guardian/caregiver if applicable; check NYSIIS when possible; recommendation of vaccination unless contraindicated; discussion of safety/effectiveness; Q&A; minimum 8 minutes of counseling; arrangement or direction for vaccination.
If contraindicated medically, counseling session is not billable.
Attestation allowed if software limitations prevent recording required documentation.

Billing Rule

Billing rule for claims submission

Billing for COVID-19 vaccine counseling and administration must follow the NCPDP D.0 claim format and include specific NCPDP fields and values. Use Professional Service Code = 'PE' (NCPDP field 440-ES) in the DUR/PPS segment and submit an amount in Incentive Amount Submitted (NCPDP field 438-E3) that is equal to or greater than the expected administration fee. Do NOT submit Professional Service Code = 'MA' (440-ES) for administration and counseling claims. The combined administration and counseling fees will be reported in Incentive Amount Paid (NCPDP field 521-FL). Ensure correct vaccine quantity and days' supply to avoid rejections.

Required: 440-ES (DUR/PPS Professional Service Code) = PE (Patient Education).
Required: 438-E3 (Pricing Segment Incentive Amount Submitted) ≥ administration fee expected (must be > $0.00).
Do NOT submit 'MA' in 440-ES for administration and counseling.
Report combined administration + counseling in 521-FL (Incentive Amount Paid).
Provide appropriate vaccine quantity (e.g., 0.5 mL when applicable) and days' supply = 1 to avoid claim rejections.
Other required NCPDP field values for initial dose processing: 420-DK = 02 (Initial Dose); 439-E4 = PP (Plan Protocol); 441-E6 = 00 (Not Specified); 409-D9 = ZS0.01 (Vaccine Cost, or follow government-supplied guidance); 426-DQ = (Usual and Customary Charge as applicable).

Key Definitions

Unvaccinated

DefinitionUnvaccinated = a patient who has not received an initial/first dose of a COVID-19 vaccine.

Eligibility implicationCounseling reimbursement is limited to unvaccinated individuals who have not received an initial/first dose and do not have an appointment for an initial dose.

LimitA provider may request reimbursement only once per unvaccinated member; counseling on second and subsequent doses is not billable.

Attestation

Permitted attestationIf pharmacy software is limited, a pharmacist may provide the attestation: 'Meets NYS DOH Counseling Criteria for COVID-19 Vaccination.'

When to useUse this attestation when the pharmacy system cannot populate required NCPDP fields or documentation elements electronically.

Documentation requirementEven when attestation is used, the counseling session must meet NYSDOH criteria and be documented in the medical or pharmacy record.

Government-supplied vaccine

DefinitionGovernment-supplied vaccine = a COVID-19 vaccine provided without cost through a government vaccine program.

Ingredient Cost SubmittedWhen vaccine provided at no cost, populate Ingredient Cost Submitted (409-D9) with either $0.01 or $0.00 per guidance (examples noted in source).

Basis of Cost DeterminationWhen vaccine provided at no cost, populate Basis of Cost Determination (423-DN) = 15 (Free product / no associated cost).

Alternate acceptable combinationProviders may submit $0.01 in 409-D9 and a Basis of Cost Determination not equal to 15, or $0.00 in 409-D9 with 423-DN = 15 as specified for federal/government-supplied vaccine programs.