Reimbursement for COVID-19 Vaccine-Only Visits for IHS-MOA Providers

Originally published March 19, 2021
Updated on September 3, 2021

Effective for dates of service on or after November 2, 2020, claims submitted by Indian Health Services-Memorandum of Agreement (IHS-MOA) providers for the administration of Coronavirus Disease 2019 (COVID-19) vaccines during vaccination-only visits are now reimbursable at fee-for-service rates. Vaccination-only visits are visits where the administration of the COVID-19 vaccine does not otherwise meet the criteria for a billable office visit. These vaccination-only visits are not reimbursable at the All-Inclusive Rate (AIR).

Reimbursement is based on the approved Centers for Medicare and Medicaid Services fee schedule rates. Effective for dates of service on or after March 15, 2021, Medi-Cal will set the maximum allowable reimbursement of the associated COVID-19 vaccine administration fee at $40.00 per dose, regardless of vaccine manufacturer or the chronological sequence of the dose. On August 12, 2021 the US Food and Drug Administration (FDA) updated the Emergency Use Authorizations (EAU) for COVID-19 vaccines to authorize the use of a third dose in certain immunocompromised individuals, specifically, solid organ transplant recipients or those who are diagnosed with conditions that are considered to be at an equivalent level.

Billing Instructions for the COVID-19 Vaccines

For billing guidance regarding the vaccines approved as of publication of this article, refer to the web pages below:

Claims submitted for COVID-19 vaccination-only visits do not currently require revenue codes for reimbursement.

Billing for Managed Care Beneficiaries

DHCS has carved out the COVID-19 vaccination-only visits from Medi-Cal Managed Care Plans (MCPs). If administering a COVID-19 vaccine during a vaccination-only visit to a beneficiary enrolled in an MCP, the guidance above applies. Vaccination-only visits are not reimbursable by the MCP. Providers are reminded to utilize the Medi-Cal Benefits Identification Card (BIC) number when submitting claims to the fee-for-service claims processing system for beneficiaries in the managed care delivery system.

The provider may submit UB-04 claims by mail to the Medi-Cal Fiscal Intermediary (FI), or electronically via Computer Media Claims (CMC). For assistance with billing, contact the Telephone Service Center at 1-800-541-5555.

Additional Information

Pharmacies, retail clinics, providers, and any other sites of care must sign an agreement with the U.S. government to receive free supplies of the COVID-19 vaccine(s).

Under the agreement, all providers must vaccinate individuals regardless of existing health coverage or the type of coverage. Providers are prohibited from balance billing or otherwise charging vaccine recipients.

In order to receive and administer COVID-19 vaccines, all California healthcare providers should refer to the enrollment instructions on the California Department of Public Health (CDPH) website, email the California COVID-19 Vaccination Program at COVIDCallCenter@cdph.ca.gov or call the COVID-19 Call Center at (833) 502-1245, Monday through Friday, from 9 a.m. to 5 p.m. More information is also available on the COVID-19 Vaccine Questions and Answers web page.

Vaccine recipients must be provided with EAU fact sheets about the vaccine and vaccination cards identifying the brand of vaccine administered and the date of their second vaccination (if applicable).

Providers must administer the vaccine in accordance with the Centers of Disease Control and Prevention (CDC) and Advisory Committee on Immunization Practices requirements. Providers must meet storage and state-mandated recordkeeping requirements, which for California includes recording the administration of the vaccine to patients in their own systems within 24 hours and to public health data systems within 24 hours.

The latest information is available on Medi-Cal’s COVID-19 Response landing page.