This page details the current Medi-Cal billing policy when submitting claims for the administration of the Moderna 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 vaccination series


• Individuals 18 years of age and older, effective for dates of service on or after December 18, 2020.


• Two dose primary series (100mcg) separated by 1 month (28 days).


• Individuals 6 months through 17 years of age, effective for dates of service on or after June 17, 2022.


• Ages 6 months to 5 years: Two dose primary series (25mcg) separated by 1 month (28 days).


• Ages 6 to 11 years: Two dose primary series (50mcg) separated by 1 month (28 days).


• Ages 12 to 17 years: Two dose primary series (100mcg) separated by 1 month (28 days).


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


• 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.


• Third dose for immunocompromised:


• The third dose should be administered no earlier than 28 days after the second dose for individuals who have undergone solid organ transplantation, or who are diagnosed with conditions that are considered to have an equivalent level of immunocompromise.


• Individuals 18 years of age and older, effective for dates of service on or after December 18, 2020.


• Individuals 6 months through 17 years of age, effective for dates of service on or after June 17, 2022.


• Monovalent booster dose for individuals 18 years of age and older:


• Effective for dates of service on or after January 7, 2022, all individuals 18 years of age or older are eligible for a single booster dose at least 5 months after completing the primary vaccination series.


• Effective for dates of service on or after November 19, 2021, all individuals 18 years of age or older are eligible for a single booster dose at least 6 months after completing the primary vaccination series.


• Effective for dates of service on or after October 20, 2021, the following groups are eligible for a booster shot at six months or more after the primary vaccination series:


• 65 years and older


• Age 18+ who live in long-term care settings


• Age 18+ who have underlying medical conditions


• Age 18+ who work or live in high-risk settings


• Moderately and severely immunocompromised individuals aged 18 years of age and older who completed a COVID-19 vaccine primary vaccination series and received a third dose of either the Pfizer-BioNTech or Moderna COVID-19 vaccine may receive a single COVID-19 booster dose (Pfizer-BioNTech, Moderna, or Janssen) at least 6 months after completing their third mRNA vaccine dose. In such situations, individuals who are moderately and severely immunocompromised may receive a total of four COVID-19 vaccine doses.


• 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.


• Second monovalent booster dose for:


• Individuals 50 years of age and older:


• Effective for dates of service on or after March 29, 2022, individuals 50 years of age and older are eligible for a second booster shot at least four months after receipt of a first booster dose of any authorized or approved COVID-19 vaccine.


• Individuals 18 years of age and older:


• Effective for dates of service on or after March 29, 2022, individuals 18 years and older who have undergone solid organ transplantation, or who are living with conditions that are considered to have an equivalent level of immunocompromise are eligible for a second booster shot at least four months after receipt of a first booster dose of any authorized or approved COVID-19 vaccine.


• Bivalent booster:


• Individuals 18 years of age and older:


• Effective for dates of service on or after August 31, 2022, individuals 18 years of age and older are eligible for a single Bivalent booster shot at least two months after completion of either the primary vaccination or most recent booster dose with any authorized/approved monovalent COVID-19 vaccine.


• Individuals 6 years of age and older:


• Effective for dates of service on or after October 12, 2022, individuals 6 years of age and older may receive a Bivalent booster dose at least two months after completing primary or booster vaccination.
• Individuals 6 months through 5 years of age:


• Effective for dates of service on or after December 8, 2022, individuals 6 months through 5 years of age may receive a booster dose at least two months after completion of a primary series with the monovalent Moderna COVID-19 Vaccine.

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 December 18, 2020:


• 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 each 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.


• Effective for dates of service on or after October 20, 2021:


• When billed appropriately, providers will be reimbursed up to the maximum allowable amount of $40.00 for the (first or second) booster.

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^®) codes when billing for these vaccines, as they are not reimbursed by Medi-Cal at this time:

• 91301 (severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2] [Coronavirus disease (COVID-19)] vaccine, mRNA-LNP, spike protein, preservative free, 100 mcg/0.5 mL dosage, for intramuscular use)


• 91306 (severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2] [coronavirus disease (COVID-19)] vaccine, mRNA-LNP, spike protein, preservative free, 50 mcg/0.25 mL dosage, for intramuscular use)


• 91309 (severe acute respiratory syndrome coronavirus 2 [SARSCoV-2] [coronavirus disease (COVID-19)] vaccine, mRNA-LNP, spike protein, preservative free, 50 mcg/0.5mL dosage, for intramuscular use)


• 91311 LNP, spike protein, preservative free, 25 mcg/0.25 mL dosage, for intramuscular use


• 91316 (severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2] [coronavirus disease (COVID-19)] vaccine, mRNA-LNP, spike protein, bivalent, preservative free, 10 mcg/0.2 mL dosage, for intramuscular use)

If providers bill using these CPT codes, 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

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

• Administration Code 0011A is for Dose 1


• Administration Code 0012A is for Dose 2


• Administration Code 0013A is for Dose 3 (for the immunocompromised)


• Administration Code 0064A is for the Monovalent Booster Dose (0.5 mL dose containing 100 mcg mRNA)


• Administration Code 0091A is for Dose 1 (ages 6 through 11)


• Administration Code 0092A is for Dose 2 (ages 6 through 11)


• Administration Code 0093A is for Dose 3 (ages 6 through 11)


• Administration Code 0094A is for the Monovalent Booster Dose (0.5 mL dose containing 50 mcg mRNA)


• Administration Code 0111A is for Dose 1


• Administration Code 0112A is for Dose 2


• Administration Code 0113A is for Dose 3


• Administration Code 0134A is for the Bivalent Booster Doses (50mcg/0.5ml) (ages 12 and older)


• Administration Code 0144A is for Bivalent Booster Dose (ages 6 through 11)


• Administration Code 0164A is for Bivalent Booster Dose (10 mcg/0.2 mL) (ages 6 months through 4 years)

There are no special instructions for hard copy or electronic medical and outpatient submissions. A booster dose of any manufacturer cannot be billed for the same recipient more than once on the same DOS.

Examples

The examples below are 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. The examples below show instances of claims for the administration of the first and second doses separately, but providers should note that the images below are merely examples, 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, however the manufacturer of the doses administered to a Medi-Cal beneficiary must remain consistent between the primary vaccination series, regardless of the administering provider. Eligible individuals may choose which vaccine they receive as a booster dose:

1) Moderna vaccine administration on a CMS-1500:

2) Moderna 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, 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.