Janssen COVID-19 Vaccine

Originally published March 3, 2021
Updated September 30, 2021

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

Current General Policy

  • The vaccine is effective for dates of service on or after February 27, 2021

Age

  • The vaccine may only be administered to patients 18 years of age and older

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 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 Providers are therefore reminded that the administration of the vaccine is reimbursable at this time, and not the vaccine itself.

Pharmacy Claims

  • Bill using NDC 59676058005

  • Claim quantity dispensed must be submitted as 0.5 mL per administered vaccine.

  • Use Submission Clarification Code (SCC) 2 (Other Override) to indicate that a COVID-19 vaccine is being administered and billed

    • Since the Janssen COVID-19 vaccine is a one-dose vaccine, providers do not need to, nor should they use SCC 6 (Starter Dose).

Electronic Submissions:

Electronic claims should also adhere to the updated Medi-Cal NCPDP Payer Sheet. Notable NCPDP D.0 submission details providers should be aware of include:

  • Use of the value “MA” (Medication Administered) in the Professional Service Code (440-E5) field is not supported in Medi-Cal and submission of that code may result in a claim denial.

  • Use of the value “PH” (Preventive Health Care) in the Reason for Service Code (439-E4) field is not supported in Medi-Cal and submission of that code may result in a claim denial.

  • Use of the value “3N” (Medication Administered) in the Result of Service Code (441-E6) field is not supported in Medi-Cal and submission of that code may result in a claim denial.

  • Use of the value “15” in the Basis of Cost Determination (423-DN) field is not supported in Medi-Cal and submission of that code may result in a claim denial. Providers are instructed to submit the value “01” instead.

  • The Quantity Dispensed (field 442-E7) should be submitted with the value that represents the quantity of drug product administered.

  • Submission Clarification Code (field 420-DK) should be submitted with a SCC code value of 2.

Examples:

The example below is included for reference only. Providers should note that this is merely an example, and that providers should adjust to their billing situation as appropriate.

Hard Copy Submissions:

Janssen COVID19 Vaccine hard copy submissions

Medical and Outpatient Claims

  • Bill using Administration Code 0031A

  • There are no special instructions for hard copy or electronic Medical or Outpatient submissions

Examples:

The example below is included for reference only. Providers should note that this is merely an example, and that providers should adjust to their billing situation as appropriate.

1) Janssen vaccine administration on a CMS-1500:

Janssen vaccine administration on CMS-1500 form

2) Janssen vaccine administration on a UB-04:

Janssen vaccine administration on UB04 form

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, providers should refer to the “Pharmacy Claim Submissions” and “Medical and Outpatient Claim Submissions” tables on the COVID-19 Medi-Cal Response page.

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.

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.