June 28, 2021
The California Medical Association (CMA) has recently received several inquiries regarding challenges with reimbursement of COVID-19 vaccine administration services. While the federal government has purchased hundreds of millions of doses of the COVID-19 vaccine and is providing those at no cost, vaccinating providers are still able to bill and be reimbursed for administering the vaccine. Providers should be aware, however, there are some nuances to successfully submitting claims for COVID-19 vaccine administration services that differ from the normal claim submission process.
Medicare Advantage Plans
For 2020 and 2021, the Centers for Medicare and Medicaid Services (CMS) is carving out the COVID-19 vaccine administration benefit from the Medicare Advantage plans and will reimburse under the Medicare fee-for-service (FFS) system. To avoid delays or denials in payment, physicians will need to ensure claims for vaccine administration for Medicare Advantage enrollees are submitted directly to Noridian, California’s Medicare Administrative Contractor, as they do for Medicare FFS claims. Claims must be submitted under the patients’ Medicare Beneficiary Identification Numbers as indicated on their original Medicare ID cards. Physicians should not bill for the vaccine itself as it is being supplied at no cost by the federal government.
Medi-Cal Managed Care
The California Department of Health Care Services (DHCS) is also carving out the COVID-19 vaccine administration reimbursement from the Medi-Cal managed care system and will reimburse under the FFS delivery system for both medical and pharmacy claims. To avoid delays and denials in payment, physicians will need to ensure claims for COVID-19 vaccine administration are submitted to Medi-Cal FFS rather than the Medi-Cal managed care plans. Physicians should follow the Provider Manual for Medi-Cal FFS Billing and submit claims with the patient’s Medi-Cal Benefit Identification Card (BIC) number rather than the Medi-Cal managed care ID number. The FFS system will only recognize the patient’s Medi-Cal BIC number. Physicians who plan to administer the vaccine but are not enrolled in the Medi-Cal system currently, can enroll through the streamlined Emergency Medi-Cal enrollment process. Failure to enroll will result in claim denials.
Blue Shield of California
Blue Shield is assuming financial responsibility for all COVID-19 vaccine administration costs, including those typically billed to its delegated groups. Effective for dates of service on and after December 11, 2020, all Blue Shield commercial HMO claims should be billed directly to Blue Shield rather than the delegated group. Vaccine administration services for other types of vaccines should continue to be billed to delegated groups in accordance with their provider agreements.
If a physician accidentally sends a claim for COVID-19 vaccine administration to a delegated group rather than Blue Shield, California regulations require the delegated group to automatically forward those misdirected claims to Blue Shield within 10 business days of receipt. Physicians should not need to resubmit claims to the health plan, but this will likely cause a delay in payment.
As a reminder, physicians who participate in the CDC COVID-19 Vaccination Program contractually agree to administer a COVID-19 vaccine regardless of an individual’s ability to pay and regardless of coverage status, and also may not seek any reimbursement from a vaccine recipient, including for CPT 99072 (PPE, cleaning supplies, disinfecting procedures, clinic time spent on pre-visit screen, etc.).
For more information, including how COVID-19 vaccine administration services will be reimbursed, see CMA’s COVID-19 Vaccine Reimbursement Quick Guide.