April 15, 2022
Effective retroactively for dates of service on or after the respective dates for each approved COVID-19 vaccine, Federally Qualified Health Center (FQHC), Rural Health Center (RHC) and Tribal FQHC providers, may receive reimbursement for administration of the Coronavirus Disease 2019 (COVID-19) vaccines during vaccine-only encounters. Vaccine-only encounters are visits where the administration of the COVID-19 vaccine does not otherwise meet the criteria for a qualifying office visit. These vaccine-only encounters are not reimbursable at the Prospective Payment System (PPS) rate for FQHC/RHC providers, nor the Alternative Payment Methodology (APM) for Tribal FQHC providers.
For COVID-19 vaccines that were administered during a qualifying office visit, FQHC, RHC, and Tribal FQHC providers are entitled to reimbursement at their individual PPS/APM rates. Providers are reminded that each administration of the COVID-19 vaccine either falls under a qualifying office visit or a vaccine-only encounter, not both. DHCS Audit & Investigations will be monitoring for program integrity.
FQHC, RHC, and Tribal FQHC providers may receive reimbursement up to a maximum allowable rate of $67.00 for COVID-19 vaccines administered during a vaccine-only encounter.
Providers Who Held Claims
Providers who held claims, as directed to by Medi-Cal in previous publications (COVID-19 Vaccine Administration: Specific Groups Advised to Hold Claim Submission article originally published on March 18, 2021), must follow the “General” instructions listed below to receive reimbursement for the vaccine-only encounter.
Medi-Cal will waive the timeliness requirement for 120 days, effective the date of this publication, for FQHC, RHC and Tribal FQHC providers to submit vaccine-only encounter claims electronically, or via hard copy with the following:
- Delay Reason Code “10”
- Documentation indicating that the COVID-19 vaccine was administered is in the Remarks area of the submitted claim (for example, “COVID-19 vaccine-only administration”)
FQHC, RHC and Tribal FQHC providers should refer to the webpages below for billing guidance and effective dates for each vaccine and dose:
Claims submitted for COVID-19 vaccine-only encounters do not currently require revenue codes for reimbursement and utilize the appropriate CPT code for the vaccine manufacturer and dose provided.
Providers Who Submitted Claims
An Erroneous Payment Correction (EPC) will be initiated to reprocess claims that were previously reimbursed at a lower maximum allowable amount, or if the amount billed was greater than or equal to the current Medi-Cal allowed amount ($67.00) at time of initial submission.
Providers who already billed Medi-Cal for the reimbursement of a COVID-19 vaccine-only encounters, and may have erroneously entered a billed amount less than intended, must follow the instructions below to manage their claims appropriately.
Claims within the timeliness guidelines (six months from the date of service):
Claims still within the timeliness standards outlined in the UB-04 Submission and Timeliness Instructions section of the Part 2 provider manual, may be voided and resubmitted either electronically or via hardcopy by providers. Upon resubmission, providers must follow the billing instructions in the “General” subheading in this article. Void and resubmission methods available to providers within this timeframe are given below:
- Electronic resubmission: Providers who elect to void and resubmit claims electronically, must follow the instructions in the Electronic Methods for Eligibility Transactions and Claim Submissions section of the Part 1 provider manual
- Hardcopy resubmission: Providers who elect to void and resubmit claims via hard copy, must request a void using the Claims Inquiry Form (CIF), and then resubmit the claim using the Appeal Form (90-1) once the provider has received confirmation of the void on their Remittance Advice Details (RAD). Instructions to complete both the CIF and 90-1 can be found in the:
Note: A void will recoup the original payment. Providers will see this recoupment reflected in the next RAD and Medi-Cal Financial Summary following the recoupment. In order for providers to receive reimbursement, they must follow the process above to completion.
Claims outside of the timeliness guidelines (more than six months from the date of service):
Claims outside of the timeliness standards outlined in the UB-04 Submission and Timeliness Instructions section of the Part 2 provider manual must be processed as follows:
- Void using the Claims Inquiry Form (CIF), and then resubmit the claim using the Appeal Form (90-1) once the provider has received confirmation of the void on their Remittance Advice Details (RAD). Instructions to complete both the CIF and 90-1 can be found in the:
- No electronic method is available at this time.
Providers must follow the billing instructions in the “General” subheading in this article for the corrected claim that is included with the Appeal.
Providers with questions may reach out to the Medi-Cal Telephone Service Center (TSC) at 1-800-541-5555, Monday through Friday, 8 a.m. to 5 p.m., excluding holidays. Additional contact options may be found on the Contact Us page of the Medi-Cal Providers website.
For instructions on how to submit or resubmit a claim with a delay reason code, or a list of all manual sections referenced in this article, providers may reference the following resources: