Prior authorization — Not applicable

Prior authorization is not required for COVID-19 vaccines or their administration.

Medicare Advantage: submit vaccine/admin codes to Original Medicare

For Medicare Advantage enrollees in 2020–2021, vaccine product and administration codes must be submitted to Original Medicare; do not bill BCBSRI for those services.

Pending FDA EUA affects billing for 91302

Code 91302 (ChAdOx1 vector) is listed as pending FDA EUA approval and was not FDA approved as of 8/31/22; providers should follow approval status before billing this product.

• 91302 is marked “PENDING FDA EUA APPROVAL (not FDA approved as of 8/31/22).

Pediatric vaccine codes — Pending CMS approval for Medicare Advantage

Several pediatric vaccine product codes (for example 91308, 91315, 91317 and associated administration codes) are marked Pending CMS approval for Medicare Advantage plans; Commercial product statuses may differ.

• 91308 and 91315 — Medicare Advantage Plans = Pending CMS approval
• 91317 — listed as Pending CMS approval for Medicare Advantage Plans

Verify coverage/prior authorization when CMS approval is pending

When a vaccine product or administration code is marked “Pending CMS approval” for Medicare Advantage, providers must verify coverage and prior authorization with BCBSRI for Medicare Advantage members before submission.

• Examples include codes such as 91316, 91310, 91309, 91311 and others marked Pending CMS approval.

Follow code-specific billing and effective-date instructions

Providers must follow the policy’s operational billing instructions when submitting claims for COVID-19 vaccines and administration, including payer- and date-specific guidance in the CPT/HCPCS code list.

• Use the specified vaccine product CPT and dose-specific administration CPT as listed in the coding section.
• Observe effective dates and plan-type instructions (Medicare Advantage vs Commercial) for each code line.

Operate per BCBSRI coding and submission guidance

Providers must adhere to BCBSRI coding and submission guidance for vaccine products and administration as specified in the policy and provider communications.

• Report the most appropriate ICD-10 diagnosis code(s) and the exact vaccine product and administration CPT/HCPCS codes.
• Follow CMS billing directives where noted (e.g., submit to Original Medicare when required).

E/M documentation must be available and provided on request

Documentation supporting a separately identifiable E/M service reported with modifier 25 must be available in the patient record and provided to BCBSRI upon request.

• Modifier 25 submission indicates documentation exists and will be provided in a timely manner for review.
• Failure to produce requested documentation may result in denial or retraction of payment.

In‑home administration (M0201) — include vaccine product and administration CPTs

When filing HCPCS M0201 for in‑home administration, the claim must also include the appropriate vaccine product CPT code and the dose‑specific vaccine administration CPT code.

• M0201 should be reported only once per home per date of service when only COVID-19 vaccine administration is performed.
• For in‑home claims include: vaccine product CPT, administration CPT, and HCPCS M0201.

Submit certain lines to Original Medicare per CMS guidance

Per CMS billing guidelines and the policy’s code table, some vaccine product and administration lines during specified periods must be submitted to Original Medicare rather than billed to BCBSRI.

• Examples: certain codes effective 10/11/20–12/31/21 are designated “submit to Original Medicare / Do Not Bill to BCBSRI.”

Refer to BCBSRI provider communications and member agreements for eligibility

Providers should consult BCBSRI provider communications and member-specific benefit documents for billing, eligibility, and payment details; the policy is informational and not a guarantee of payment.

• For member-specific benefits call the provider call center and review the subscriber/employer agreements.

Failure to produce documentation may lead to denial or payment retraction

Failure to produce requested documentation for services may result in claim denial or retraction of payment.

Claims denied if vaccine supplied to provider at no cost

Claims for vaccine product line items will be denied as provider liability (no member liability) if the vaccine was supplied to the provider at no cost.

• Providers should not append modifier 22 to vaccine codes to indicate provider purchase; claims will be denied if vaccine was supplied at no cost.

Do not bill BCBSRI when CMS directs submission to Original Medicare

Do not bill BCBSRI for certain vaccine products during periods when CMS guidance directs submission to Original Medicare; those lines are marked Do Not Bill / submit to Original Medicare.

• Example: several vaccine product CPTs had CMS-designated periods (e.g., 10/11/20–12/31/21) requiring submission to Original Medicare.

No reimbursement to BCBSRI for vaccine products received at no cost

Multiple vaccine product CPTs (for example 91306, 91309, 91313) are marked as having no reimbursement for claims submitted to BCBSRI when providers receive the vaccine product at no cost.

• These product lines include explicit ‘No reimbursement for claims submitted to BCBSRI for vaccine products health care providers receive at no cost’ statements.

No reimbursement when vaccine product received at no cost

Claims submitted to BCBSRI for vaccine products that health care providers receive at no cost will not be reimbursed.

• Policy states vaccines supplied to providers at no cost will not have any reimbursement if filed by a provider; such claims will be denied as provider liability.