Pfizer-BioNTech COVID-19 Vaccine

Originally published March 3, 2021
Updated October 26, 2021

This page details the current Medi-Cal billing policy when submitting claims for the administration of either dose of the Pfizer-BioNTech 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:

    • The first two doses of the vaccine are effective for dates of service on or after December 11, 2020.

    • The second dose should be administered no earlier than 17 days after the first dose.

    • Effective for dates of service on or after August 12, 2021, a 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.

    • Effective for dates of service on or after December 11, 2020, the primary vaccination series may be administered to patients 16 years of age and older.

    • Effective for dates of service on or after May 10, 2021, the primary vaccination series may be administered to patients 12 years of age and older.

    • 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.
  • Booster Dose:

    • Effective for dates of service on of after September 22, 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
    • 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 December 11, 2020 through March 14, 2021:

    • When billed appropriately, providers will be reimbursed up to the maximum allowable amount of $16.94 for a 0.3 mL first dose.

    • When billed appropriately, providers will be reimbursed up to the maximum allowable amount of $28.39 for a 0.3 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 0.3 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 is 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:

  • 91300 (severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2] [Coronavirus disease (COVID-19)] vaccine, mRNA-LNP, spike protein, preservative free, 30 mcg/0.3 mL dosage, diluent reconstituted, 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

  • Bill using NDC 59267100001

  • Claim quantity dispensed must be submitted as 0.3 mL per administered vaccine.

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 COVID-19 vaccine is being administered and billed

  • Use SCC 6 (Starter Dose) to indicate that the second dose of a COVID-19 vaccine is being administered and billed

  • Use SCC 7 to indicate that a third dose of a COVID-19 vaccine is being administered and billed

  • Use SCC 10 to indicate that a booster dose of the COVID-19 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 (420-DK) field should be submitted with SCC code values of 2,6, 7, or 10 to indicate first, second, third, or booster 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 the dose being administered.

    • 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 second dose is being administered and billed

    • Enter either a 3 or 03 to indicate that the third dose is being administered and billed

    • Enter either a 4 or 04 to indicate that a booster 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 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 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 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:

Electronic submissions:

NCPDP D.o transactions - SCC values

Hard Copy submissions:

1) Pfizer-BioNTech initial dose:

Pfizer-BioNTech initial dose

2) Pfizer-BioNTech second dose:

Pfizer-BioNTech final dose

Medical and Outpatient Claims

  • Bill Dose 1 using Administration Code 0001A

  • Bill Dose 2 using Administration Code 0002A

  • Bill Dose 3 using Administration Code 0003A

  • Bill the Booster Dose using Administration Code 0004A

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 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 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) Pfizer-BioNTech on a CMS-1500:

Pfizer BioNTech vaccine CMS-1500

2) Pfizer-BioNTech on a UB-04:

Pfizer BioNTech vaccine UB-04

FDA Approval of Pfizer-BioNTech COVID-19 Vaccine

On August 23, 2021, the FDA formally approved the biologics license application (BLA) for Pfizer-BioNTech’s COVID-19 vaccine, commercially known as Comirnaty. Currently, the FDA approval applies to the administration of the vaccine in individuals 16 years of age and older.

The amended Pfizer-BioNTech COVID-19 vaccine EUA still remains in effect however, and allows for:

  • individuals 12 through 15 years of age to receive the Pfizer-BioNTech COVID-19 vaccine,

  • the administration of a third dose to certain immunocompromised individuals,

  • the administration of a booster dose to certain populations.

Medi-Cal’s policy regarding the Pfizer-BioNTech vaccine and the administration of the vaccine, with respect to the formal FDA approval of the Comirnaty product and the existing EUA, remains unchanged. The most current Medi-Cal billing guidelines regarding the Pfizer-BioNTech COVID-19 vaccine is published on this web page.

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.