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

Originally published December 29, 2020
Updated on March 3, 2021
Most recent updates are denoted with two plus signs (++)

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.

Some highlights that Medi-Cal wishes medical and outpatient 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 the following vaccine manufacturers:

  • As other vaccine manufacturers are approved by the FDA, additional billing instructions will be issued. Providers should refer to the COVID-19 Medi-Cal Response page for specific billing information for approved vaccines.

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

    • ++The system changes to properly adjudicate most medical and outpatient claims submission (both electronic and paper) were implemented on January 25, 2021.

    • ++Medi-Cal was able to receive these claims as of Tuesday, December 29, 2020. The claims were not adjudicated, however, until the necessary system changes were implemented and may have appeared to be in “pending” status for a period of time if submitted between December 29, 2020, and January 25, 2021.

    • ++Now that the required system changes have been implemented, most claims submitted during this time frame have been released for adjudication. Claims with Other Health Coverage (OHC) indicators will continue to be in “pending” status until further notice. Providers will be notified via a subsequent News article when these submissions 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.

++As of original publication of this article, and outlined above, when medical and outpatient claims were initially submitted, they were put into “pending” status until the claims processing systems that Medi-Cal utilizes could be updated to appropriately adjudicate submissions. Medi-Cal can now process all medical and outpatient claims. Any prior pauses in payment:

  • Should not be cause for providers to decline administering initial or secondary doses of currently approved COVID-19 vaccines

  • Should not delay timely submission of COVID-19 vaccine administration claims.

++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.