Tricare, the government payer for families of active duty military, has some very peculiar rules about how it wants vaccine claims sent. Your practice may be getting overpaid or underpaid (or both!) if it is not following the Tricare rules.
When you submit a CPT code for a vaccine to Tricare, you must also include an NDC number with the appropriate NDC suffix.
In general, Tricare wants you to use the individual (not bulk) vaccine NDC code, along with the suffix “UN1.”
Rotavirus vaccine is an exception — for these, use the individual NDC code, the suffix “ML2,” and the modifier F2. (The modifier goes in the same place as you would normally put a modifier -25 or -59.)
Update: There are some vaccines that Tricare wants you to submit using the NDC suffix “0.5 ML” instead.
What’s the difference between individual and bulk vaccine NDC codes? Most vaccines come in packages of 5 or 10 vaccines. That multi-dose “package” has an NDC number, which is different than the “unit dose” NDC of a vaccine that’s administered. The unit dose NDC may be printed on the individual vaccine vial syringe — or maybe not.
If you use the bulk vaccine NDC code, Tricare’s computers will sometimes assume that you are claiming you gave all 5-10 doses to that one patient (yes, that’s crazy) and will pay you up to 5x or 10x the usual amount. (Typically, this is capped out at whatever your charge is.)
You can look up whether your vaccine NDC is an “individual” or “bulk” NDC code here:
In this example, the tan line indicates the bulk/package NDC code and the blue line indicates the individual/unit dose NDC code.
How can I tell if I’ve been overpaid, underpaid, or neither for a particular vaccine dose?
Compare your total payments to Tricare’s fee schedule. At a minimum, you should be paid above your cost for vaccines. You may see a pattern of many doses of a particular vaccine being paid at or slightly above the CDC private reference price, but with other doses being paid at 25%, 50%, 200%, or 400% of that amount.