SPBM: Pediatric Vaccine Claims Processing | November 3, 2022 Update
Ohio SPBM Pharmacy Providers,
In an effort to increase vaccine access for children, the Ohio Department of Medicaid (ODM) has recently created provisions to allow pharmacies contracted with Gainwell Technologies SPBM to administer pediatric vaccinations to eligible Medicaid members regardless of the pharmacy’s status as a Vaccines for Children Program (VFC) provider.
VFC providers should submit vaccination claims with zero ingredient cost and Basis of Cost Determination (NCPDP field 423-DN) value of “15”. Pharmacies will only be eligible to receive the administration incentive payment in these instances.
Non-VFC providers should submit vaccination claims which include an ingredient cost. Pharmacies will receive reimbursement for ingredient cost plus the administration incentive payment.
If you have questions, please contact the Gainwell SPBM Customer Service Center at 833-491-0344 or email OH_MCD_PBM@gainwelltechnologies.com.
OH Pharmacy Network Contracting