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COVID-19 Medi-Cal Response

The Department of Health Care Services (DHCS) continues to closely monitor and respond to COVID-19 and is providing information on this web page to all providers as a reminder of recommended safety procedures and protocols from the federal Centers for Disease Control and Prevention (CDC) and California Department of Public Health (CDPH) to help prevent spread of COVID-19. Providers are encouraged to check this page for regular updates to the Medi-Cal response to COVID-19, as well as the Medi-Cal homepage.


Frequently Asked Questions (FAQs)

Vaccine Administration

Current Direction on Claims Submission

To assist providers with claims submission for the administration of the COVID-19 vaccine, Medi-Cal has provided a summary of the most current direction that providers are being asked to follow regarding the various submission methods that Medi-Cal accepts. This table is updated as changes are made to the claims adjudication system, to allow for more submission methods to be used to submit COVID-19 vaccine administration claims.

Pharmacy providers seeking to submit hardcopy or electronic claims should refer to the Medi-Cal Rx website for submission and billing instructions.

Pfizer-BioNTech

Dose 837 v.5010 IPCS CMS-1500 UB-04
First Dose Yes Yes Yes Yes
Second Dose Yes Yes Yes Yes
Third Dose Yes Yes Yes Yes
First Booster Dose Yes Yes Yes Yes
Second Booster Dose Yes Yes Yes Yes

Refer to the Pfizer-BioNTech Vaccine Guidelines web page for specific age restrictions and formulations that Medi-Cal currently supports.

Moderna

Dose 837 v.5010 IPCS CMS-1500 UB-04
First Dose Yes Yes Yes Yes
Second Dose Yes Yes Yes Yes
Third Dose Yes Yes Yes Yes
First Booster Dose Yes Yes Yes Yes
Second Booster Dose Yes Yes Yes Yes

Refer to the Moderna Vaccine Guidelines web page for specific age restrictions and formulations that Medi-Cal currently supports.

Note: Medi-Cal currently cannot process the Moderna formulation defined under CPT code 0094A.

Janssen

Dose 837 v.5010 IPCS CMS-1500 UB-04
First Dose Yes Yes Yes Yes
Booster Dose Yes Yes Yes Yes

Refer to the Janssen Vaccine Guidelines web page for specific age restrictions and formulations that Medi-Cal currently supports.

Novavax

Dose 837 v.5010 IPCS CMS-1500 UB-04
First Dose Yes Yes Yes Yes
Second Dose Yes Yes Yes Yes

Refer to the Novavax Vaccine Guidelines web page for specific age restrictions and formulations that Medi-Cal currently supports.


Medi-Cal can process all medical and outpatient claims for the administration of the primary vaccination series for currently approved or authorized COVID-19 vaccines. Any prior pauses in payment:

  • Should not be cause for providers to decline administering initial or secondary doses of currently approved COVID-19 vaccines.
  • Should not delay timely submission of COVID-19 vaccine administration claims.

Additionally, providers are reminded that:

  • Dose administrations may be billed separately, or multiple on the same claim, whichever fits the provider’s billing preferences and practices. Claims submitted should adhere to the timeliness guidelines described in the Part 1 provider manual section, Claim Submission and Timeliness Overview.
  • There is no requirement for the same provider to administer all doses. Each dose is separately reimbursable.
  • The manufacturer of the doses administered to a Medi-Cal beneficiary must remain consistent between the primary vaccination series doses, regardless of the administering provider.
  • Eligible individuals may choose which vaccine they receive as a booster dose. The eligible population(s) and dosing interval for the heterologous (mix and match) booster dose are the same as those authorized for a booster dose of the vaccine used for primary vaccination.

For specific billing guidance, providers should refer to the most current articles listed below:

Current Vaccine Guidance

Current Monoclonal Antibody Guidance

Recently Published Vaccine or Therapeutics Articles

  • Expanded Use of Bivalent Dosages Approved for Children Six Months and Up
  • Bebtelovimab No Longer Authorized to Treat COVID-19
  • TAR Requirement Removal and FDA Approvals for Veklury®
  • Coming Soon: Expanded Use of Bivalent Dosages Approved for Children 6 Months and Up
  • Booster Dose for Novavax and Pediatric Bivalent Pfizer-BioNTech and Moderna COVID-19 Vaccines
  • Coming Soon: Booster Dose for Novavax and Pediatric Bivalent Pfizer-BioNTech and Moderna COVID-19 Vaccines
  • Policy Update and Billing Guidance for COVID-19 Oral Antiviral, Paxlovid
  • Billing Update for Bebtelovimab Use for COVID-19 Treatment
  • Addition of Novavax COVID-19 Vaccine
  • Coming Soon: Bivalent Booster Dose for Select COVID-19 Vaccines
  • Reminder: COVID-19 Oral Antivirals for Uninsured Group
  • Coming Soon: Novavax COVID-19 Vaccine Authorization
  • FDA Approves COVID-19 Vaccine for Children 6 Months and Up
  • Coming Soon: COVID-19 Vaccine for Children 6 Months and Up
  • Pfizer COVID-19 Vaccine Booster Dose Approved for Individuals 5 to 11 Years Old
  • Second Booster Dose for Select COVID-19 Boosters Now a Benefit
  • Update: FQHC, RHC and Tribal FQHC Providers Claim Submission for COVID-19 Vaccine Administration
  • Coming Soon: Second Booster Dose for Select COVID-19 Vaccines
  • Bebtelovimab Administration added as New COVID-19 Monoclonal Antibody Benefit
  • Providers Holding Submissions of Claims for COVID-19 Vaccine Administration May Now Submit
  • Home Health Agency Providers May Be Reimbursed for COVID-19 Vaccine Administration
  • Pharmacy Providers to Bill Medi-Cal Rx for COVID-19 Vaccine Administration
  • New Public Health Order requires workers in adult and senior care facilities and in-home direct care settings to be vaccinated by November 30
  • COVID-19 Vaccination Administration Reimbursable for Ambulance Providers
  • Supplemental Rate for Administration of COVID-19 Vaccine in Home Setting

    • Previously Published Vaccine or Monoclonal Antibody Articles

  • FQHC, RHC and Tribal FQHC Providers May Now Submit Claims for COVID-19 Vaccine Administration
  • Sotrovimab No Longer Authorized to Treat COVID-19
  • Pfizer-BioNTech COVID-19 Vaccine Updates for Third Dose, Booster Dose and Shortening of its Time Requirements
  • Eligibility of Pfizer-BioNTech COVID-19 Booster Dose Expanded to 16 Years of Age and Older
  • Eligibility of COVID-19 Booster Doses Expanded to All Adults
  • Pfizer-BioNTech COVID-19 Vaccine for Children 5 through 11 Can Be Processed
  • Booster Dose for Janssen COVID-19 Vaccine Can Be Processed
  • Heterologous (Mix and Match) COVID-19 Vaccine Booster Doses are Authorized
  • Booster Dose for Moderna COVID-19 Vaccine Can Be Processed
  • Booster Dose for Pfizer-BioNTech COVID-19 Vaccine Can Be Processed
  • Third Dose for Pfizer-BioNTech and Moderna COVID-19 Vaccines: Pharmacy Batch and Hard Copy Claims
  • Coming Soon: Pfizer-BioNTech COVID-19 Vaccine is Authorized for Children 5 through 11
  • Coming Soon: Booster Dose for Janssen COVID-19 Vaccine is Authorized
  • Coming Soon: Booster Dose for Pfizer-BioNTech COVID-19 Vaccine is Authorized for Certain Populations
  • Third Dose for Pfizer-BioNTech and Moderna COVID-19 Vaccines Can Be Processed
  • Third Dose for Pfizer-BioNTech and Moderna COVID-19 Vaccines Authorized for Certain Populations
  • Coming Soon: Third Dose for Pfizer-BioNTech and Moderna COVID-19 Vaccines Authorized
  • New Age Restriction for Pfizer-BioNTech COVID-19 Vaccine
  • New NDC for Moderna COVID-19 Vaccine
  • Reimbursement for COVID-19 Vaccine-Only Visits for IHS-MOA Providers
  • COVID-19 Vaccine Administration: Specific Groups Advised to Hold Claim Submission
  • Change to COVID-19 Vaccine Administration Maximum Allowable Rate
  • Vaccines for People with High-Risk Medical Conditions or Disabilities
  • Coronavirus Disease 2019 (COVID-19) Uninsured Group – Vaccine Reimbursement
  • COVID-19 Vaccine Administration: COVID-19 Uninsured Group – Vaccine Reimbursement
  • COVID-19 Vaccine Administration: Initial and Upcoming Policy
  • COVID-19 Vaccine Administration: Preparing to Submit Medical and Outpatient Claims
  • COVID-19 Vaccine Administration: Preparing to Electronically Submit Pharmacy Claims
  • COVID-19 Vaccine Administration: Real-Time NCPDP D.0 Pharmacy Claims Can Be Submitted
  • COVID-19 Vaccine Administration: Medical and Outpatient Claims Can Be Submitted
  • COVID-19 Vaccine Administration: Pharmacy Batch and Hard Copy Claims Can Be Submitted
  • COVID-19 Vaccine Administration: Medical and Outpatient Claims Now Adjudicating
  • COVID-19 Vaccine Administration: Preparing NCPDP 1.2 and Pharmacy Hard Copy Submissions
  • COVID-19 Vaccine Administration: Real-Time RTIP Pharmacy Claims Can Be Submitted
  • COVID-19 Vaccine Administration: Real-Time NCPDP D.0 Pharmacy Claims Submission Reminders

    • Additional COVID-19 Related Articles

    Testing Guidance

    Family PACT Guidance

    FQHC, RHC and IHS-MOA Providers

    Recipient Eligibility and Enrollment Guidance

    Additional Guidance

    Over-the-Counter COVID-19 Antigen Test Kits

    Manual Sections

    User Guides

    Other Resources

    Transactions
    Provider
    Support
    Statewide Campaigns
    Website Accessibility Certification