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Medi-Cal Update

Medical Transportation | October 2021 | Bulletin 553

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1. Third Dose for Pfizer-BioNTech and Moderna COVID-19 Vaccines Authorized for Certain Populations

Effective for dates of service on or after August 12, 2021, the U.S. Food and Drug Administration (FDA) amended the Emergency Use Authorizations (EUA) for the Pfizer-BioNTech and Moderna COVID-19 vaccines to permit the administration of a third dose to certain individuals with compromised immune systems. For the most current direction regarding guidelines for use of these vaccines, including how to bill for the administration of a third dose, refer to the following COVID-19 vaccine web pages:

To assist providers, billing guidelines specific to administration of a third dose are published below.

Providers should note that all billing guidelines included below are only current as of the publication of this article.

General Policy

  • The third dose should be administered no earlier than 28 days following the two-dose regimen of the same vaccine to individuals who have undergone solid organ transplantation, or who are diagnosed with conditions that are considered to have an equivalent level of immunocompromise.

  • Age restrictions for use of the vaccine product are not changed with this update.

  • The policy for maximum allowable reimbursement is not changed with this update.

Pharmacy Claims

  • Use previously published National Drug Codes (NDC) associated with the Pfizer-BioNTech and Moderna COVID-19 vaccines to indicate the third dose in claims submitted both electronically and on paper. In addition,

    • When submitting electronic claims utilizing NCPDP D.0, NCPDP 1.2, or RTIP transactions, providers should use Submission Clarification Code (SCC) 7 to indicate that a third dose of a COVID-19 vaccine is being administered and billed.

    • When submitting hard copy claims, providers should enter either a 3 or 03 in the Fill Number field (Box 12) to indicate that the third dose is being administered and billed.

  • Batch (NCPDP 1.2) and paper claims (30-1) may be suspended upon submission until further system updates required to properly adjudicate those claims are implemented. Pharmacy providers will be informed when these system updates are implemented.

Medical and Outpatient Claims

  • Pfizer-BioNTech: Administration of a third dose must be indicated by using CPT® code 0003A.

  • Moderna: Administration of a third dose must be indicated by using CPT® code 0013A.

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. As of the publication of this article, the FDA approval applies to the administration of the vaccine in individuals 16 years of age and older.

The original Pfizer-BioNTech COVID-19 vaccine EUA still remains in effect, however, and allows individuals 12 through 15 years of age to receive the Pfizer-BioNTech COVID-19 vaccine, and also allows for the administration of a third dose to certain immunocompromised individuals.

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 as of the original publication of this article. Providers should refer to the Pfizer-BioNTech COVID-19 Vaccine web page on the Medi-Cal Provider website for the most current billing guidelines that should be followed when submitting a claim to Medi-Cal for the administration of a Pfizer-BioNTech COVID-19 vaccine.

Additional Information

The NCPDP Payer Sheet is updated as of publication of this article. Provider manual updates reflecting these changes will be released in a future Medi-Cal Update.

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.

2. Supplemental Rate for Administration of COVID-19 Vaccine in Home Setting

General Policy

Effective for dates of service on or after June 8, 2021, Medi-Cal will reimburse providers an additional $35.00 per dose when administering a Coronavirus Disease 2019 (COVID-19) vaccine in the home of a Medi-Cal beneficiary who is unable to travel to a vaccination site. This supplemental rate is to be in addition to the $40.00 maximum allowable reimbursement currently in effect for each COVID-19 vaccine. Current reimbursement rates and billing instructions regarding each of the COVID-19 vaccines is located on the following web pages:

The supplemental Medi-Cal reimbursement is only applicable if the sole purpose of the visit is to administer a COVID-19 vaccine. The additional amount is not reimbursable if another service, separate from the administration of a COVID-19 vaccine, is provided in the same home on the same date of service. In the instance of another service being a part of the visit, Medi-Cal will only reimburse the COVID-19 vaccine administration based on the base maximum allowable reimbursement and will not apply the supplemental rate.

The supplemental home administration fee is designed to target Medi-Cal beneficiaries that have difficulty leaving the home to get the vaccine, which could mean any of these:

  • They have a condition, due to an illness or injury, that restricts their ability to leave home without a supportive device or help from a paid or unpaid caregiver

  • They have a condition that makes them more susceptible to contracting a pandemic disease like COVID-19

  • They are generally unable to leave the home, and if they do leave home it requires a considerable and taxing effort

  • The patient is hard-to-reach because they have a disability or face clinical, socioeconomic, or geographical barriers to getting a COVID-19 vaccine in settings other than their home.

Detailed Policy

For dates of service between June 8, 2021, and August 23, 2021, if a provider administers the COVID-19 vaccine to more than one beneficiary in a single home on the same day, Medi-Cal will reimburse the additional $35.00 reimbursement only once per date of service in that home.

  • For example, if a provider administers a single-dose vaccine on the same date to two Medi-Cal patients in the same home, Medi-Cal will reimburse one payment of $35.00 for the in-home vaccine administration rate, plus $40.00 for each dose of the COVID-19 vaccine administered. The total reimbursement in this scenario would be $115.00.

For dates of service on or after August 24, 2021, if the vaccine is administered to fewer than 10 Medi-Cal beneficiaries on the same day residing in the same home, Medi-Cal will reimburse up to a maximum of five times when multiple Medi-Cal patients are vaccinated in the same home.

  • For example, if a provider administers six vaccines to Medi-Cal patients in the same home, Medi-Cal will reimburse five payments of $35.00 for the in-home vaccine administration rate, plus $40.00 for each dose of the COVID-19 vaccine administered. For a total reimbursement of $415.00.

Locations that can qualify as a patient’s home for the additional in-home payment amount, includes, but is not limited to, the following:

  • A private residence

  • Temporary lodging (for example, a hotel or motel, campground, hostel, or homeless shelter)

  • An apartment in an apartment complex or a unit in an assisted living facility or group home

  • When the patient’s home has been made provider-based to a hospital during the COVID-19 Public Health Emergency (PHE)

However, the following locations are not considered “homes” that can qualify for the additional payment amount:

  • Communal spaces of a multi-unit living arrangement

  • Hospitals (except when the Medicare patient’s home has been made provider-based to a hospital during the COVID-19 PHE)

  • Skilled nursing facilities (SNFs), regardless of whether they are the patient’s permanent residence

  • Assisted living facilities participating in the CDC’s Pharmacy Partnership for Long-Term Care Program when their residents are vaccinated through this program

How to Bill

Medical and Outpatient providers should denote this additional service on the same claim as the vaccine administration, using HCPCS code M0201 (COVID-19 vaccine administration inside a patient’s home; reported only once per individual per date of service when only COVID-19 vaccine administration is performed at the patient’s home).

Pharmacy providers should denote this additional service on the same claim as the vaccine administration, using NDC 99999999995.

Providers who administered a COVID-19 vaccine in a beneficiary’s home but did not originally submit vaccine administration claims with this billing instruction are instructed to submit a separate claim for applicable dates of service.

Additional Information

Additional information regarding these updates can be found in the Immunizations section in Part 2 of the Medi-Cal Provider Manual.

3. Updated Policy for Palivizumab for the 2021–2022 RSV Season

Effective for dates of services on or after August 19, 2021, and continuing for the 2021–2022 respiratory syncytial virus (RSV) season only, county RSV positivity data for the time period reflecting the administered dose of Palivizumab (CPT® code 90378 [respiratory syncytial virus, monoclonal antibody, recombinant, for intramuscular use, 50 mg, each]) is no longer required to be accompanied with a Treatment Authorization Request (TAR) for doses submitted outside the time period of a typical RSV season such as 2019–2020. Additional information can be found below.

Resources:

Provider Manual(s) Page(s) Updated
Chronic Dialysis Clinics
Clinics and Hospitals
General Medicine
Obstetrics
Pharmacy
Rehabilitations Clinics
immun (62, 64)

4. Medi-Cal Rates Adjustment

Effective for dates of service on or after October 1, 2021, Medi-Cal rates have been adjusted to adhere to requirements mandated by the Centers for Medicare and Medicaid Services (CMS).

The updated Medi-Cal rates are available on the Medi-Cal Rates page.

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6. Provider Manual Revisions



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