Effective for dates of service (DOS) on or after March 29, 2022, the U.S. Food and Drug Administration (FDA) amended the Emergency Use Authorization (EUA) for the Pfizer-BioNTech COVID-19 vaccine and Moderna COVID-19 vaccine, to allow for use of a second booster dose, to be administered at least four months after initial booster dose, to the following groups for each respective vaccine:

Pfizer-BioNTech:

• Individuals 12 years of age or older with certain kinds of immunocompromise. This includes individuals who have undergone solid organ transplantation, or who are living with conditions that are considered to have an equivalent level of immunocompromise.


• Individuals 50 years of age and older.

Moderna:

• Individuals 18 years of age or older with certain kinds of immunocompromise. This includes individuals who have undergone solid organ transplantation, or who are living with conditions that are considered to have an equivalent level of immunocompromise.


• Individuals 50 years of age and older.

Providers may now submit claims for second booster dose administration using the following codes:

• Pfizer:


• Administration Code 0004A for the originally authorized formulation (phosphate buffered saline)


• Administration Code 0054A is for the Tris buffered formulation


• Moderna:


• Administration Code 0064A


• Administration Code 0094A for new booster formulation (50 mcg/0.5 ml)

Billing:

Providers can now bill for administration code 0094A. A booster dose of any manufacturer cannot be billed for the same recipient more than once on the same DOS.

For the most current information regarding Medi-Cal’s COVID-19 response, see the COVID-19 Medi-Cal Response page on the Medi-Cal Provider website.

Effective for dates of service on or after March 29, 2022, the minimum age for HCPCS code J0741 (injection, cabotegravir and rilpivirine, 2 mg/3 mg), Cabenuva, is reduced from 18 years of age to 12. Cabenuva contains the two long-acting HIV-1 antiretroviral drugs cabotegravir and rilpivirine.

In addition, the network of specialty pharmacies, specialty distributors and wholesalers for Cabenuva have been updated to reflect current offerings and contact information.

An Erroneous Payment Correction (EPC) will be implemented to reprocess denied claims with dates of service on or after March 29, 2022, that were appropriately submitted based on the guidance published in this article but erroneously denied because Medi-Cal had not yet implemented the system changes to support appropriate adjudication. Providers may also elect to use this updated billing policy to correct and resubmit previously denied claims as described in the CIF Submission and Timeliness Instructions section of the Provider Manual.

As previously announced in the News article titled “Hepatitis B Vaccine Code 90759 is Now a Medi-Cal Benefit,” effective for dates of service on or after January 1, 2022, CPT^® code 90759 (hepatitis B vaccine [HepB], 3-antigen [S, Pre-S1, Pre-S2], 10 mcg dosage, 3 dose schedule, for intramuscular use) is a Medi-Cal benefit.

CPT code 90759 is reimbursable for recipients 18 years of age or older and modifiers SA, SB, U7, UD and 99 are allowable.

A Treatment Authorization Request (TAR) is not required for reimbursement.

As a reminder, for physician-administrated drugs (PAD) that are assigned a Conversion Indicator equal to 30, the price listed on the Medi-Cal Rates page of the Medi-Cal Providers website includes the one-time injection administration fee of $4.46. Since the injection administration fee is applied only once for each drug administered, subsequent units claimed will have the administration fee subtracted from the published rate.

Examples of the correct way to calculate this fee below:

Billed units: 2

• Correct: ($4.96 x 1 unit) + ($4.96 - $4.46 admin fee) x 1 unit = $5.46


• Incorrect: $4.96 x 2 units = $9.92

Billed units: 4

• Correct: ($7.50 x 1 unit) + ($7.50 - $4.46 admin fee) x 3 units = $16.62


• Incorrect: $7.50 x 4 units = $30.00

Providers can refer to the Medi-Cal Rates Conversion page, the Injections: An Overview section of the Medi-Cal providers manual or contact our Telephone Service Center (TSC) at 1-800-541-5555 to receive further assistance.

The Centers for Medicare & Medicaid Services (CMS) has released the quarterly National Correct Coding Initiative (NCCI) payment policy updates. These mandatory national edits have been incorporated into the Medi-Cal claims processing system and are effective for claims received on or after July 1, 2022.

For additional information, refer to The National Correct Coding Initiative in Medicaid page of the Medicaid website.

Medi-Cal's Outreach and Education department, along with the Department of Health Care Services is offering a “Coffee Break” event in July for category specific topics.

Topics discussed will include the following:

Providers may visit the Medi-Cal Learning Portal (MLP) to view available coffee break times and to register in the Event Calendar.

Providers are encouraged to bring questions relating to the “Coffee Break” session topic. This is an open forum, therefore, claim examples are not needed for this event.

For additional assistance, contact the Telephone Service Center (TSC) at 1-800-541-5555.

Outreach and Education (O&E) along with the Department of Health Care Services (DHCS) are offering category specific webinar sessions in August.

A variety of courses will be offered in each of the categories listed. Providers must register through the Medi-Cal Learning Portal (MLP) Event Calendar.

Providers will be able to print class materials and ask questions during the training sessions.

To view the webinars, providers must have internet access and a user profile in the MLP. Detailed instructions about the registration process and how to access webinar classes are available on the Outreach & Education page of the Medi-Cal Providers website.

For additional assistance, contact the Telephone Service Center (TSC) at 1-800-541-5555.

The Medi-Cal Subscription Service (MCSS) is a free service that keeps you up-to-date on the latest Medi-Cal news. Subscribers receive subject-specific emails shortly after urgent announcements and other updates post on the Medi-Cal website.

Subscribing is simple and free!

1. Go to the MCSS Subscriber Form


2. Enter your email address and ZIP code and select a subscriber type


3. Customize your subscription by selecting subject areas for NewsFlash announcements, Medi-Cal Update bulletins and/or System Status Alerts

After submitting the form, a welcome email will be sent to the provided email address. If you are unable to locate the welcome email in your inbox, check your junk email folder.

For more information about MCSS, please visit the MCSS Help page.

Pages updated due to ongoing provider manual revisions: