COVID-19 Vaccine Administration: Medical and Outpatient Claims Can Be Submitted

Originally published December 29, 2020
Updated on January 6, 2021

This is the sixth article in the COVID-19 Vaccine Administration series and informs medical and outpatient providers that they may begin submitting claims electronically or via hard copy to Medi-Cal for the COVID-19 vaccine administration as specified in an earlier News article titled “COVID-19 Vaccine Administration: Preparing to Submit Medical and Outpatient Claims”.

Some highlights that Medi-Cal wishes providers to remain aware of as they begin submission are outlined below. In addition, clarification on system changes, reimbursement, and timelines has been added.

  • The 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.

  • DHCS will reimburse the associated COVID-19 vaccine administration fee at the Medicare allowable rate for all claim types.

    • When billed appropriately, providers will be reimbursed $16.94 for the first dose and $28.39 for the second dose (regardless of manufacturer).

    • Claims are subject to all other applicable billing and program requirements.

    • Medi-Cal reimbursement is for the COVID-19 vaccine administration, and not the vaccine itself.

  • DHCS has sought federal approval to pay for the vaccine administration fee 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.

  • 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 the current Prospective Payment System (PPS) or All-Inclusive Rate (AIR) which FQHC, RHC and IHS-MOA Clinic providers receive for reimbursement.

  • System and operational changes are required to enable successful claims adjudication.

    • The system changes for medical and outpatient claims submission (both electronic and paper) are in flight.

    • Medi-Cal is prepared to begin receiving these claims as of Tuesday, December 29, 2020. The claims will not be adjudicated, however, until the necessary system changes have been implemented and will appear in “pending” status for a period of time.

    • Once the required system changes have been implemented in late January 2021, the claims will be released for adjudication.

    • Note, although all reasonable measures have been taken to isolate and pend these claims during this period, it is possible some claims may be inadvertently processed and/or denied. Medi-Cal will automatically reprocess, via Erroneous Payment Correction (EPC), any claims meeting these conditions post system change implementation.

  • 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.

  • Providers should not use the following 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)

As outlined above, when medical and outpatient claims are initially submitted, they will be put into “pending” status until the claims processing systems that Medi-Cal utilizes can be updated to accurately adjudicate submissions. This pause in payment should not:

  • Be cause for providers to decline administering COVID-19 vaccine initial or secondary doses.

  • Be cause for providers to delay in submitting claims for administration of initial or secondary doses of the COVID-19 vaccine.

Medical and outpatient providers will be notified in a forthcoming News article when they should begin to see claims adjudication outcomes for submitted COVID-19 vaccine administration claims.