MedicaidReimbursementHigh impact
Newsletter Vol. 34, No.11
New Jersey Medicaid·NJ · Pharmacy·Provider Notice
Effective date
Oct 1, 2024
We identified it
Jun 20, 2026
Summary
Effective October 1, 2024, New Jersey Medicaid reimbursement for pharmacist-administered COVID-19 vaccines changes from Medicare-aligned rates to Actual Acquisition Cost (AAC) plus a $10.92 professional fee. Pharmacies must discontinue populating three NCPDP fields (420-DK, 440-E5, 438-E3) and stop receiving incentive fee payments in Field 521-FL. Pharmacies must continue updating the New Jersey Immunization Information System (NJIIS) within 48 hours of vaccine administration.
Action Required
By October 1, 2024: (1) Billing team must reconfigure pharmacy billing system to calculate COVID-19 vaccine administration reimbursement as AAC + $10.92 professional fee instead of previous Medicare-aligned rates. (2) Update billing software to STOP populating NCPDP Field 420-DK (Submission Clarification Code), Field 440-E5 (Professional Service Code), and Field 438-E3 (Incentive Amount Submitted). (3) Remove expectation of receiving incentive fee payments in NCPDP Field 521-FL. (4) Pharmacy staff must verify NJIIS system prior to each COVID-19 vaccine administration to prevent duplicates and continue submitting immunization records to NJIIS within 48 hours post-administration. (5) Notify all participating pharmacies of rate changes and new billing procedures. Failure to implement these changes will result in claim denials or underpayment for COVID-19 vaccine administrations under New Jersey FamilyCare/Medicaid.