COVID-19 Vaccine Administration: Specific Groups Advised to Hold Claim Submission

Originally published March 18, 2021
Updated on April 15, 2022

The information below, originally published on March 18, 2021, has been updated. The updated information is outlined in the Februar 24, 2022, article titled “Providers Holding Submissions of Claims for COVID-19 Vaccine Administration May Now Submit ” published on the Medi-Cal Providers website. Providers seeking the latest claim submission guidance from Medi-Cal for the populations addressed in this original article should refer to the February 24, 2022, article. DHCS has not received a response on the SPA for FQHC’s and RHC’s and therefore those entities must still hold vaccine only claims as outlined below.

On April 15, 2022, Medi-Cal published that FQHC and RHC providers, as well as Tribal FQHC providers, can submit claims, in the article titled: FQHC, RHC and Tribal FQHC Providers May Now Submit Claims for COVID-19 Vaccine Administration.

As noted in the publication originally published December 22, 2020, and updated on March 3, 2021, the Department of Health Care Services (DHCS) submitted a federal waiver request in December 2020 to the Centers for Medicare and Medicaid Services (CMS) seeking federal approval to cover the cost of vaccine administration for 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 Group program. In addition, DHCS has submitted a State Plan Amendment to request approval from CMS to reimburse Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs) a fee-for-service rate for vaccine administration when the encounter does not meet all of the requirements of a billable visit (i.e. vaccine-only administration).

Providers who have administered the COVID-19 vaccines to beneficiaries who are included in:

  • The Family PACT program

  • The COVID-19 Uninsured Group program

Are advised to hold submission of claims pending further guidance from DHCS.

Similarly, FQHCs and RHCs should hold claims for vaccine-only administration to the extent the encounter does not meet the requirements of a billable visit or the beneficiary being served is in one of the identified populations noted above. Policy and reimbursement guidance will be updated upon additional CMS guidance and/or approvals of the requested waiver/State Plan Amendment.

Updates regarding IHS-MOA 638 clinics are forthcoming.

Providers with questions should contact the Telephone Service Center (TSC) at 1-800-541-5555. The TSC is available 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.