This page details the current Medi-Cal billing policy when submitting claims for the administration of the Janssen COVID-19 vaccine.

Current General Policy

• 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.


• Primary Vaccine Series:
  
  
  • The Janssen vaccine is a one-dose primary vaccination series.
  
  
  • Effective for dates of service on or after February 27, 2021, the primary vaccination series may only be administered to patients 18 years of age and older.
  
  
• Booster Dose:
  
  
  • Effective for dates of service on or after October 20, 2021, a booster dose is recommended for individuals 18 years of age and older at least two months (eight weeks) after completing their Janssen primary vaccination series.
  
  
  • 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.

Maximum Allowable Reimbursement

• Effective for dates of service on or after February 27, 2021 through March 14, 2021:


• When billed appropriately, providers will be reimbursed up to the maximum allowable amount of $28.39 for a 0.5 mL dose


• Effective for dates of service on or after February 27, 2021:


• Federally Qualified Health Center (FQHC), Rural Health Clinic (RHC) and Tribal FQHC providers, may be reimbursed up to the maximum allowable amount of $67.00 for each dose of the COVID-19 vaccine administered.


• Effective for dates of service on or after March 15, 2021:


• When billed appropriately, providers will be reimbursed up to the maximum allowable amount of $40.00 for a 0.5 mL dose


• Effective for dates of service on or after June 8, 2021:


• When billed appropriately, providers will be reimbursed a supplemental amount of $35.00 per dose when administering a COVID-19 vaccine in the home of a Medi-Cal beneficiary who is unable to travel to a vaccination site


• Billing instructions on how to claim this additional supplemental amount are available in the Immunizations provider manual section in the appropriate Part 2 manual

If claims do not meet the billing instructions listed above or in the following sections, they will be denied or result in an incorrect payment. Additionally, providers should not use the following Current Procedural Terminology (CPT^®) code when billing for these vaccines, as it is not reimbursed by Medi-Cal at this time:

• 91303 (severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2] [Coronavirus disease (COVID-19)] vaccine, DNA, spike protein, adenovirus type 26 [Ad26] vector, preservative free, 5x10¹⁰ viral particles/0.5 mL dosage, for intramuscular use)

If providers bill using this CPT code, they may receive a Remittance Advice Details (RAD) code of 0145: This procedure is not a Medi-Cal benefit on this date of service, and are therefore reminded that the administration of the vaccine is reimbursable at this time, and not the vaccine itself.

Pharmacy Claims

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

Medical and Outpatient Claims

• Bill the primary vaccine dose using Administration Code 0031A
• Bill the booster dose using Administration Code 0034A
• There are no special instructions for hard copy or electronic Medical or Outpatient submissions

Examples:

The example below is included for reference only. When submitting claims providers are able to bill for administration of each dose separately, or multiple on the same claim form, whichever fits their individual preference or billing practice. Providers should note that this is merely an example, and that providers should adjust to their billing situation as appropriate. There is no requirement for the same provider to administer all doses. Each dose is separately reimbursable. Eligible individuals may choose which vaccine they receive as a booster dose.

1) Janssen vaccine administration on a CMS-1500:

2) Janssen vaccine administration on a UB-04:

Additional References:

An FAQ regarding the administration of the COVID-19 vaccines is available on the DHCS website. The FAQ is updated as needed.

For the most current direction regarding whether or not claims should be submitted, and what behavior to expect when submitting, Medi-Cal providers should refer to the “Medical and Outpatient Claim Submissions” tables on the COVID-19 Medi-Cal Response page. Medi-Cal Rx providers should refer to information on the Medi-Cal Rx website.

This guidance is only effective for COVID-19 vaccines purchased by the federal government. At a future date, the Department of Health Care Services (DHCS) will provide an end date to this temporary policy and instruct providers on how they should bill for the reimbursement of provider purchased COVID-19 vaccines.

Medi-Cal providers with questions should contact the Telephone Service Center (TSC) Help Desk at 1-800-541-5555, 8 a.m. to 5 p.m., Monday through Friday, except holidays. Border providers and out-of-state billers billing for in-state providers, should call 1-916-636-1200.