Over the past year or so, some practices have had problems claiming reimbursement for drugs, such as flu vaccines. In particular, some have been told by ICBs or NHSE that their claims are too late and so can't be processed or paid. A common question is about the period within which claims for certain drugs can be submitted. What is the legal position?
The Statement of Financial Entitlements (SFE) for General Medical Services (GMS) sets out the rules on claiming reimbursement for drugs. Part 5, Item 16 of the SFE Directions 2024 outlines the rules for submitting claims for eligible Prescription Pricing Authority (PPA) drugs. It specifies that claims must be submitted by the 5th of the month following the use of the drug.
It is Part 5 which has caused the confusion. It was not intended to (and does not) set out a "hard" deadline. However, we understand that some commissioners have interpreted it as doing just that and have rejected claims on that basis.
Part 7, Section 10 of the SFE Directions makes it clear that the deadline for submitting a claim is in fact six years after the date the drugs were first used. This provision is intended to safeguard practices against administrative errors, missed claims, or incorrect submissions, providing an extended window to rectify mistakes or submit omitted claims.
Flu vaccines and high-volume claims
Despite the broad applicability of the six-year claim period, some confusion persists – especially regarding flu vaccines. In particular, practices have raised concerns about whether the flu vaccine is subject to different rules due to its classification as a high-volume vaccine. The NHS, via Public Health England, holds the budget for flu vaccines and has imposed stricter administrative conditions, such as the requirement to submit flu vaccine claims in bulk.
However, again, this bulk submission requirement is purely for processing efficiency and does not change the six-year claim period. The fundamental rule of the six-year submission window applies to all PPA-eligible drugs, including flu vaccines. The same time limits and procedures should apply as with other drugs, unless specific alternative time limits are set or exceptional circumstances justify a deviation.
Addressing the confusion
The primary cause of the confusion seems to be differing interpretations of the SFE by NHS England (NHSE) and Integrated Care Boards (ICBs). While there may be nuances in the application of rules for high-volume vaccines like flu, the legal interpretation of the SFE Directions is clear: practices have six years to claim for eligible PPA drugs and that applies universally, regardless of the drug in question.
If practices have had claims rejected on the basis that they are out of time, they should review them carefully and should challenge such a decision (as long as it falls within the six-year window). Denying claims within this period not only undermines fairness but also constitutes a breach of the SFE Directions.
Any practices who still do not have success with any such challenges should contact Oliver Pool opool@vwv.co.uk or Andrew Andrews aandrews@vwv.co.uk.
*The views expressed are the author’s and not ICAEW’s
