COVID-19 Vaccine Administration: Preparing to Submit Medical and Outpatient Claims

Originally published December 28, 2020
Updated on January 6, 2021

Current Guidance

This is the fourth article in the COVID-19 Vaccine Administration series and covers how providers should plan to submit their claims in the coming weeks. However, providers should continue to hold on submitting their claims to Medi-Cal at this time. Providers will be notified in a future News article when Medi-Cal is ready to intake claims for the COVID-19 vaccine administration.

As previously announced, with the recent federal approval of COVID-19 vaccines, the Department of Health Care Services (DHCS) is seeking federal approval to help support delivery of the vaccine to all Medi-Cal beneficiaries. DHCS will follow California’s COVID-19 vaccination plan, which was approved by the California Department of Public Health (CDPH). In order to receive and administer COVID-19 vaccines, all California healthcare providers will enroll in the federal COVID-19 Vaccination Program electronically through CDPH’s provider registration and enrollment system at the COVIDReadi website. Enrollment is limited at this time to providers authorized by their local health department (LHD). Others may enroll later in January as vaccine supply increases. Before enrolling, providers need to obtain their immunization information system (IIS) ID at the California Immunization Record (CAIR2) website. Once providers have been invited by their LHD and have their IIS ID, they should confirm that they meet all requirements listed in the COVIDReadi Provider Enrollment Instructions before enrolling. For further information on the state’s vaccination planning efforts please visit https://covid19.ca.gov/vaccines/.

Even though providers are being asked to continue to hold their claims at this time, providers are encouraged to begin administration of the vaccine in accordance with the CDPH Allocation Guidelines for COVID-19 Vaccine During Phase 1A. Providers must keep the manufacturer consistent between doses; if the first dose administered to a patient is the Pfizer-BioNTech vaccine, then the second dose administered to the same patient must also be the Pfizer-BioNTech vaccine.

Additionally, as the federal government will pay for the initial vaccines, there is no Medi-Cal provider reimbursement for the COVID-19 vaccine itself. DHCS plans to reimburse the associated COVID-19 vaccine administration fee at the Medicare allowable rate for all claim types, based on the number of required doses. DHCS has requested federal approval to provide coverage of vaccine administration for Medi-Cal beneficiaries who have restricted scope coverage or who are enrolled in the Family Planning, Access, Care, and Treatment (Family PACT) program, as well as the COVID-19 Uninsured population. In addition, DHCS has sought federal approval to pay Federally Qualified Health Centers (FQHCs), Rural Health Clinics (RHCs), and Indian Health Service (IHS) – Memorandum of Agreement (MOA) 638 Clinics for the vaccine administration fee outside of their current Prospective Payment System (PPS) or All-Inclusive Rate (AIR).

Once Medi-Cal announces that medical and outpatient claims for the COVID-19 vaccine administration can be submitted, Medi-Cal providers can bill for administration of the COVID-19 vaccine using the electronic or paper submission methods in use today. All other program policy billing requirements remain in effect. 

Preparing to Bill

Currently the U. S. Food and Drug Administration (FDA) has provided Emergency Use Authorization (EUA) for two vaccine manufacturers: Pfizer-BioNTech and Moderna. As other vaccine manufacturers are approved by the FDA, additional billing instructions will be issued.

As such medical and outpatient providers should bill as specified below for each respective vaccine and dose:

  • Pfizer-BioNTech COVID-19 Vaccine (NDC 59267100001)

    • Effective for dates of service on or after December 11, 2020

    • May only be administered to patients 16 years of age and older

    • Dose 1:

      • Bill using Administration Code 0001A

      • When billed appropriately, providers will be reimbursed $16.94 for a 0.3 mL first dose

    • Dose 2:

      • Administer no earlier than 17 days after the first dose

      • Bill using Administration Code 0002A

      • When billed appropriately, providers will be reimbursed $28.39 for a 0.3 mL second dose

  • Moderna COVID-19 Vaccine (NDC 80777027310)

    • Effective for dates of service on or after December 18, 2020

    • May only be administered to patients 18 years of age and older

    • Dose 1:

      • Bill using Administration Code 0011A

      • When billed appropriately, providers will be reimbursed $16.94 for a 0.5 mL first dose

    • Dose 2:

      • Administer no earlier than 24 days after the first dose

      • Bill using Administration Code 0012A

      • When billed appropriately, providers will be reimbursed $28.39 for a 0.5 mL second dose

As stated previously, while medical and outpatient providers can prepare to submit claims, they should continue to hold on submitting said claims, either electronically or via hard copy submission, until further notice.

Lastly, once claims can be submitted to Medi-Cal, whether billed electronically or on paper, if they do not meet the billing instructions listed above, they will be denied or result in an incorrect payment. 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:

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

  • 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 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, and are therefore reminded that it is the administration of the vaccine that is reimbursable at this time, and not the vaccine itself.

Billing Examples

To assist medical and outpatient providers in billing and to avoid claim adjudication issues, billing examples have been prepared as a point of reference. Note that these are merely examples, and that providers should adjust to their billing situation as appropriate:

1) Pfizer BioNTech vaccine administration on a CMS-1500:

Pfizer BioNTech vaccine CMS-1500

2) Moderna vaccine administration on a CMS-1500:

Moderna vaccine CMS-1500

3) Pfizer BioNTech vaccine administration on a UB-04:

Pfizer BioNTech vaccine UB-04

4) Moderna vaccine administration on a UB-04:

Moderna vaccine UB-04

FQHC/RHC and IHS-MOA Clinic providers are reminded that DHCS has sought federal approval to pay for the vaccine administration fee outside of the current PPS or AIR of which FQHC/RHC and IHS-MOA Clinic providers receive for reimbursement. Note, the UB-04 billing examples depicted in this article are appropriate for FQHC/RHC and IHS-MOA Clinic claims submission reference. If a PPS/AIR service visit was also provided, in addition to the vaccine administration, both services may be billed on the same claim form if desired.

Upcoming Updates

More updates regarding when providers may begin submitting medical and outpatient claims and how to bill for additional vaccines will be shared as they are made available.  An FAQ regarding the administration of the COVID-19 vaccines will be made available on the Medi-Cal website in the near future.

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.