Moderna COVID-19 Vaccine

Originally published March 3, 2021
updated on May 5, 2021

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

Current General Policy

  • The vaccine is effective for dates of service on or after December 18, 2020.

  • The second dose should be administered no earlier than 24 days after the first dose.

  • Dose administrations may be billed separately, or together on the same claim, whichever fits the provider’s billing preferences and practices.

  • There is no requirement for the same provider to administer both doses. Each dose is separately reimbursable.

  • The manufacturer of the doses administered to a Medi-Cal beneficiary must remain consistent between the first and second dose, regardless of the administering provider.

Age

Effective for dates of service on or after December 18, 2020, 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 December 18, 2020 through March 14, 2021:

    • When billed appropriately, providers will be reimbursed up to the maximum allowable amount of $16.94 for a 0.5 mL first dose.

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

If claims do not adhere to the billing instructions listed above or in the following sections, they will be denied or result in an incorrect reimbursement. 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:

  • 91301 (severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2] [Coronavirus diseases (COVID-19)] vaccine, mRNA-LNP, spike protein, preservative free, 100 mcg/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.

Pharmacy Claims

  • NDC 80777027310 is effective for dates of service on or after December 18, 2020.

  • NDC 80777027315 is effective for dates of service on or after April 1, 2021.

  • Claim quantity dispensed must be submitted as 0.5 mL per administered vaccine, regardless of NDC used.

Electronic Submissions:

The following instructions apply to NCPDP D.0, NCPDP 1.2, and RTIP submissions.

  • Use Submission Clarification Code (SCC) 2 (Other Override) to indicate that the first dose of a two-dose vaccine is being administered and billed

  • Use SCC 6 (Starter Dose) to indicate that the final dose of a two-dose vaccine is being administered and billed

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 SCC code values of 2 or 6 to indicate first dose or second dose, respectively.

Hard Copy Submissions:

The following instructions apply to Pharmacy Claim Form (30-1) submissions:

  • Use the Fill Number field (Box 12) to indicate if the dose being administered is the initial or final dose.

    • Enter either a 0 or 00 to indicate that the initial dose is being administered and billed

    • Enter either a 1 or 01 to indicate that the final dose is being administered and billed

Examples:

The examples below are included for reference only. When submitting claims providers are able to bill for administration of the initial or final dose separately, or together, whichever fits their individual preference or billing practice. The examples below show instances of claims for the administration of the initial and final doses separately, but providers should note that these are merely examples, and that providers should adjust to their billing situation as appropriate. There is no requirement for the same provider to administer both doses. Each dose is separately reimbursable, however the manufacturer of the doses administered to a Medi-Cal beneficiary must remain consistent between the first and second dose, regardless of the administering provider:

Electronic submissions:

NCPDP D.o transactions - SCC values

Hard Copy submissions:

1) Moderna initial dose:

Moderna initial dose

2) Moderna final dose:

Moderna final dose

Medical and Outpatient Claims

  • Bill Dose 1 using Administration Code 0011A

  • Bill Dose 2 using Administration Code 0012A

There are no special instructions for hard copy or electronic medical and outpatient submissions

Examples:

The examples below are included for reference only. When submitting claims providers are able to bill for administration of the initial or final dose separately, or together, whichever fits their individual preference or billing practice. The examples below show instances of claims for the administration of the initial and final doses on the same claim or transaction, but providers should note that these are merely examples, and that providers should adjust to their billing situation as appropriate. There is no requirement for the same provider to administer both doses. Each dose is separately reimbursable, however the manufacturer of the doses administered to a Medi-Cal beneficiary must remain consistent between the first and second dose, regardless of the administering provider:

1) Moderna vaccine administration on a CMS-1500:

Moderna vaccine CMS-1500

2) Moderna vaccine administration on a UB-04:

Moderna vaccine 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, 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, 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.