CurrentDell Children's Health PlanPolicy N/A

COVID-19 Vaccine Administration Procedure Codes Are Now Benefits of Medicaid and CHIP

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This policy explains Medicaid and CHIP coverage, reimbursement, billing restrictions, and claim reprocessing for specified bivalent COVID-19 vaccine administration procedure codes. It applies to participating providers and eligible places of service under Dell Children's Health Plan in Texas.

Policy Summary

PayerDell Children's Health Plan

PolicyCOVID-19 Vaccine Administration Procedure Codes Are Now Benefits of Medicaid and CHIP

Policy CodePolicy N/A

Change TypeAdded and clarified

Effective Date04/18/2023

Next Review DateN/A

Key ActionBill the covered vaccine administration codes to MCOs retroactively for applicable dates of service on or after April 18, 2023.

SourceLink

POLICY UPDATE CHANGES

Six COVID-19 vaccine administration procedure codes became Medicaid and CHIP benefits for dates of service on or after April 18, 2023.

The policy clarifies billing, place-of-service, provider eligibility, claim reprocessing, and same-day billing requirements for the covered administration codes.

6COVID-19 vaccine administration codes covered

08/31/2023NRP reimbursement end date

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CurrentDell Children's Health PlanPolicy N/A

COVID-19 Vaccine Administration Procedure Codes Are Now Benefits of Medicaid and CHIP

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Sign up for all dellchildrenshealthplan policy alerts

Know when dellchildrenshealthplan releases new policies or updates existing guidance.

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Policy Summary

PayerDell Children's Health Plan

PolicyCOVID-19 Vaccine Administration Procedure Codes Are Now Benefits of Medicaid and CHIP

Policy CodePolicy N/A

Change TypeAdded and clarified

Effective Date04/18/2023

Next Review DateN/A

Key ActionBill the covered vaccine administration codes to MCOs retroactively for applicable dates of service on or after April 18, 2023.

SourceLink

POLICY UPDATE CHANGES

Six COVID-19 vaccine administration procedure codes became Medicaid and CHIP benefits for dates of service on or after April 18, 2023.

The policy clarifies billing, place-of-service, provider eligibility, claim reprocessing, and same-day billing requirements for the covered administration codes.

6COVID-19 vaccine administration codes covered

08/31/2023NRP reimbursement end date

Coverage Criteria

Covered administration code criteria

Covered for Medicaid and CHIP when ALL of the following criteria are met:

ALL of the following

Administration code, age, and vaccine product
- One covered administration code and corresponding eligibility
  - Procedure code 0121A is used for administration of the first dose of the bivalent Pfizer-BioNTech vaccine to individuals 12 years of age or older.
  - Procedure codes 0141A and 0142A are used for administration of the first and second doses, respectively, of the bivalent Moderna vaccine to individuals 6 months through 11 years of age.
  - Procedure code 0151A is used for administration of the first dose of the bivalent Pfizer-BioNTech vaccine to individuals 5 through 11 years of age.
  - Procedure codes 0171A and 0172A are used for administration of the first and second doses, respectively, of the bivalent Pfizer-BioNTech vaccine to individuals 6 months through 4 years of age.
The date of service is April 18, 2023, or later, consistent with the FDA's amended emergency use authorizations.>= April 18, 2023
- Eligible place of service and provider type
  - Office: physician assistant (PA), nurse practitioner (NP), clinical nurse specialist (CNS), physician, pharmacist, certified nurse midwife (CNM), federally qualified health center (FQHC), nephrology (hemodialysis or renal dialysis), rural health clinic (RHC), or pharmacy.
  - Home: PA, NP, CNS, physician, home health agency, or Comprehensive Care Program (CCP) provider.
  - Outpatient hospital: FQHC, hospital, nephrology (hemodialysis or renal dialysis), or renal provider.
  - Other location: PA, NP, CNS, physician, FQHC, CCP provider, or RHC.
FQHCs and RHCs may be reimbursed separately for these COVID-19 vaccine administration codes only for dates of service from April 18, 2023, through May 11, 2023.April 18–May 11, 2023
This separate reimbursement limitation applies to FQHCs and RHCs.
The administration is eligible for non-risk payment under the Medicaid and CHIP COVID-19 reimbursement criteria.Through August 31, 2023
The NRP COVID-19 reimbursement criteria have an end date of service of August 31, 2023.

Vaccine product code status

The vaccine product codes are not separately reimbursed while the vaccines are supplied to providers free of charge.

Procedure codes 91312, 91314, 91315, and 91317 remain informational only and are not separately reimbursed while the vaccine is distributed to providers free of charge.

Billing restrictions

Apply the following billing restrictions and operational requirements when submitting claims.

Procedure code M0201 (COVID-19 vaccine administration inside a patient's home) may be billed in the home setting with procedure code 0121A, 0141A, 0142A, 0151A, 0171A, or 0172A as of April 18, 2023.
Procedure code G0315 cannot be billed on the same day by the same provider as procedure code 0121A, 0141A, 0142A, 0151A, 0171A, or 0172A.
Claims containing both services on the same day by the same provider are subject to the billing restriction.
Dell Children's Health Plan must reprocess affected claims submitted with these administration procedure codes for dates of service on or after April 18, 2023.
Providers do not need to appeal unless the claim remains denied for additional reasons after reprocessing.
Providers may bill MCOs retroactively for COVID-19 vaccine administration procedure codes 0121A, 0141A, 0142A, 0151A, 0171A, and 0172A.

Covered Codes and Billing Parameters

Covered COVID-19 vaccine administration procedure codesCPTCovered

0121A	Administration of the first dose of the bivalent Pfizer-BioNTech vaccine for individuals age 12 years or older
0141A	Administration of the first dose of the bivalent Moderna vaccine for individuals age 6 months through 11 years
0142A	Administration of the second dose of the bivalent Moderna vaccine for individuals age 6 months through 11 years
0151A	Administration of the first dose of the bivalent Pfizer-BioNTech vaccine for individuals age 5 through 11 years
0171A	Administration of the first dose of the bivalent Pfizer-BioNTech vaccine for individuals age 6 months through 4 years
0172A	Administration of the second dose of the bivalent Pfizer-BioNTech vaccine for individuals age 6 months through 4 years

COVID-19 vaccine product codesCPT

91312	COVID-19 vaccine product code; informational only while vaccine is distributed free of charge
91314	COVID-19 vaccine product code; informational only while vaccine is distributed free of charge
91315	COVID-19 vaccine product code; informational only while vaccine is distributed free of charge
91317	COVID-19 vaccine product code; informational only while vaccine is distributed free of charge

Home administration add-on billingHCPCSCovered

M0201

COVID-19 vaccine administration inside a patient's home

Same-day billing exclusionHCPCSNot Covered

G0315

Code that cannot be billed on the same day by the same provider as the covered COVID-19 vaccine administration codes

Coverage effective date

Coverage effective dateDates of service on or after April 18, 2023

Covered benefitCOVID-19 vaccine administration procedure codes are benefits for Medicaid and CHIP

Applicable vaccine productsBivalent Pfizer-BioNTech and Moderna COVID-19 vaccines

NRP reimbursement end date

NRP reimbursement end dateAugust 31, 2023

Applies toCOVID-19 vaccine administration procedure codes 0121A, 0141A, 0142A, 0151A, 0171A, and 0172A

Provider Billing Actions

Billing Rule

Retroactive Billing

Providers may bill MCOs retroactively for covered COVID-19 vaccine administration codes for dates of service on or after April 18, 2023.

0121A
0141A
0142A
0151A
0171A
0172A

Billing Rule

Claim Reprocessing and Appeals

Dell Children's Health Plan must reprocess affected claims submitted with the covered COVID-19 vaccine administration codes for dates of service on or after April 18, 2023. Providers generally do not need to appeal after reprocessing unless a claim remains denied for an additional reason; appeal any remaining denial as appropriate.

Definitions

Non-risk payments

Payment sourceTexas Health and Human Services Commission (HHSC)

Payment typeNon-risk payments

Covered servicesCOVID-19 vaccine administration procedure codes 0121A, 0141A, 0142A, 0151A, 0171A, and 0172A

Covered administration codes

0121AAdministration of the first dose of the bivalent Pfizer-BioNTech vaccine for individuals age 12 years or older

0141AAdministration of the first dose of the bivalent Moderna vaccine for individuals age 6 months through 11 years

0142A