Submitting claim forms

Use this guidance when submitting claims for HEPLISAV-B in the office/noninstitutional setting (CMS-1500 form). First, complete the top half of the claim form with the patient’s information. Then, fill in the product and diagnosis codes in the sections indicated in the sample form below

CMS-1500 Claims Form for HEPLISAV-B CMS-1500 Claims Form for HEPLISAV-B
  • Box 17B: Include the NPI number for the ordering/referring physician
  • Box 21: Report the diagnosis codes along with any other diagnoses relevant to the patient’s episode of care on this Date of Service
  • Box 24A: Include the NDC within the shaded area above the Date of Service
  • Box 24D: Include the CPT code for HEPLISAV-B: 90739
    • Append any necessary modifiers (check for ICD-10 code and diabetes) for proper claim processing
  • Box 24E: Include the ICD-10 code linked to the CPT code to support medical necessity
  • Box 31: Sign if necessary and submit the claim form per the insurance carrier’s/insurer’s instructions

Call HEPLISAV-B Access Navigator™* at 1-84-HEPLISAV (1-844-375-4728) for coverage and reimbursement support 8 am to 8 pm, ET, Monday through Friday

*While many health insurance plans cover HEPLISAV-B, the type and level of coverage can vary. Any information provided by a HEPLISAV-B Access Navigator is intended as a guideline only, and is not a guarantee of coverage. Coverage and reimbursement amounts are specific to the individual plan that a member or their employee has purchased, as well as the negotiated contract for each provider. Each plan decides its own reimbursement rate, which varies based on plan and patient group. Dynavax suggests that you contact the individual plan to determine reimbursement.

Tips for submitting claims

Private payer reimbursement varies and is based on the rate contracted with the provider

Additional tips for Medicare patients

Additional resources

Reimbursement — Submitting Claims
HEPLISAV-B Hepatitis B Vaccine (Recombinant), Adjuvanted™ HEPLISAV-B Hepatitis B Vaccine (Recombinant), Adjuvanted™

Thank you for your submission. An automated email containing the Enrollment Letter will be sent to you shortly.

Call 1-84-HEPLISAV (1-844-375-4728)
8 AM to 8 PM, ET, Monday through Friday