Rx30 Vaccine Medical Billing

Overview

Rx30 Vaccine Medical Billing allows pharmacies to submit eligible vaccine claims through a patient's medical benefit using Outcomes. Most commonly, pharmacies use this process to bill Medicare Part B-covered vaccines, but it can also support other medical payers when the pharmacy has the appropriate contracts and enrollment in place.

This guide walks through:

• How to submit a vaccine for medical billing in Rx30
• How to check patient eligibility
• How to add a diagnosis code
• Required Rx30 setup steps

Before You Begin

Before submitting vaccine claims for medical billing, make sure:

✅ The pharmacy has completed Outcomes medical billing enrollment forms.

✅ The administering pharmacist's NPI has been configured in Rx30.

✅ The appropriate in-house cash plan has been created in Rx30.

✅ The patient's coverage has been verified.

How to Submit a Vaccine for Medical Billing in Rx30

Submitting a medically billed vaccine is very similar to processing a standard fill. The primary differences are selecting the correct in-house cash plan and including a diagnosis code.

Step 1: Enter the Vaccine Fill

Enter the vaccine as you normally would in Rx30.

No special prescription entry process or alternate workflow is required.

Step 2: Select the Appropriate In-House Cash Plan

The in-house cash plan tells Outcomes that the vaccine should be submitted through the patient's medical benefit.

Medicare Part B Vaccines:

• Use Plan Code: 026183

• This plan is typically used for Medicare Part B-covered vaccines, including:

  • Influenza (flu)

  • Pneumococcal
  • Hepatitis B
  • COVID-19

Commercial or Other Medical Billing:

• Use Plan Code: COMM1

• If you have not yet configured these plans in Rx30, see the Setup section below.

Step 3: Add a Diagnosis Code

A diagnosis code is required for medical claim submission.

To Add a Diagnosis Code:

1. While entering the vaccine, navigate to: F10 > Edit > #20
2. Enter the appropriate ICD-10 diagnosis code.
3. Select F4 to save.

For routine immunization encounters, the diagnosis code is often: Z23 – Encounter for Immunization

Step 4: Submit the Claim

Complete the remaining vaccine information as you normally would.

When the prescription is processed:

• Outcomes will attempt to bill the vaccine product.
• Outcomes will attempt to bill the vaccine administration.
• The claim will be submitted through the patient's medical benefit based on the plan selected.

Checking Patient Eligibility

Before administering a vaccine, we recommend verifying the patient's eligibility and active coverage.

Performing an eligibility check can help reduce claim rejections and identify coverage issues before services are provided.

How to Check Eligibility in Rx30

1. Open the patient record.
2. Navigate to F10 Edit.
3. Select 22 Eligibility.

Review the patient's eligibility information and confirm active coverage before proceeding.

Adding a Diagnosis Code in Rx30

Medical claims require a diagnosis code.

If one was not entered during initial prescription entry, follow these steps:

1. Navigate to: F10 > Edit > #20
2. Enter the appropriate ICD-10 diagnosis code.
3. Select F4 to save your changes.

Rx30 Setup Requirements

The following setup steps only need to be completed once.

Configure Pharmacist NPI Information

The administering pharmacist's NPI is submitted on the medical claim as the rendering provider.

To Add an NPI:

1. Navigate to: Menu > System > Employee
2. Select the employee who will administer vaccines.
3. Enter:
   • Provider ID = Pharmacist NPI
   • Qualifier = 05
4. Save your changes.

Repeat these steps for all pharmacists who will administer medically billed vaccines.

Create the Medicare Part B In-House Cash Plan

Step 1: Create the Plan

Navigate to: F1 Menu > Data > 04 Third Plans

Enter the following information:

Select F4 Save.

Adding the In-House Cash Plan in Rx30 informs Outcomes that the claim should be medically billed.

Step 2: Configure Required Fields

After saving:

1. Select F5 Rqmts
2. Ensure the following fields are set to Y:

• Cash Plan
• Cardholder ID
• Person Code
• Group Number
• Track Claims
• Track $0 Claims

1. Select F1 Return
2. Select F4 Save

Your Medicare Part B billing plan is now configured.

Screenshots below for reference: 

 Quick Tips for Successful Claim Submission

• Verify patient eligibility before administering the vaccine.
• Use the correct in-house cash plan.
• Include a diagnosis code on all medical claims.
• Ensure the administering pharmacist's NPI is configured in Rx30.
• Verify that the pharmacy has any required payer enrollment or contracting in place.
• Review claim responses and remittance information regularly to identify billing issues early.