Originally published October 26, 2021
Updated October 29, 2021
Previously, on October 8, 2021, Medi-Cal advised providers to hold claim submission for booster doses of the Pfizer-BioNTech vaccine until appropriate system updates could be implemented to properly adjudicate claims.
As of the publication of this article, Medi-Cal can now accept most Medical, Outpatient, and Pharmacy claims for the administration of a booster dose of the Pfizer-BioNTech COVID-19 vaccine.
- Medical and outpatient providers may submit via either electronic or hard copy methods; whatever suits their preference.
- Pharmacy providers may only submit via NCPDP D.0 or RTIP at this time. Providers wishing to submit claims to Medi-Cal via NCPDP 1.2 (batch) or hard-copy claim methods, should hold their claims until further notice.
DHCS is aggressively pursuing the necessary required system changes to support the adjudication of the batch and hard-copy Pharmacy claims and will inform providers when the system is ready to process NCPDP 1.2 or hard-copy submission methods.
For the most current direction regarding eligible populations and booster dose billing guidelines, refer to the Pfizer-BioNTech COVID-19 Vaccine web page.
Additionally, effective for dates of service on or after October 8, 2021, eligible individuals may choose which vaccine they receive as a booster dose. The eligible population(s) and dosing interval for the heterologous (mix and match) booster dose are the same as those authorized for a booster dose of the vaccine used for primary vaccination. Medi-Cal is prepared to receive claims for the administration of a heterologous booster dose for the Moderna or Janssen COVID-19 vaccines, and providers are encouraged to bill at their earliest convenience.
Billing and eligibility guidelines for booster doses are available on the Pfizer-BioNTech COVID-19 Vaccine, Moderna COVID-19 Vaccine, or Janssen COVID-19 Vaccine web pages.
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.