July 15, 2021
Area(s) of Interest: Payor Issues and Reimbursement
Blue Shield of California has identified a system issue that caused COVID-19 vaccine administration claims for patients ages 12-17 to be denied in error. Claims processed between May 12 and June 21, 2021, were affected and erroneously denied with a message that the claim line was denied per Centers for Medicare & Medicaid Services/Blue Shield guidelines.
Blue Shield corrected the system edit causing the denials for enrollees aged 12-17 on June 22, 2021, and is working to automatically identify and reprocess all affected claims. No further action is required by physician practices. Blue Shield advised that physicians will begin seeing the reprocessed payments by August 13. Blue Shield will issue payment, including interest. as applicable.
On May 12, 2021, the California Department of Public Health expanded COVID-19 vaccine eligibility to individuals 12 and older for the Pfizer vaccine. In mid-June, the California Medical Association (CMA) began receiving calls from practices receiving Blue Shield denials for COVID-19 vaccine administration services in patients ages 12-17.
It is also important to note that Blue Shield has assumed all financial responsibility of payment for COVID-19 vaccine administration services. For Blue Shield HMO patients, this means that rather than billing the delegated group, practices should bill Blue Shield directly COVID-19 vaccine administration services. All other vaccines will continue to be billed to the delegated groups. For more information click here.
If a claim is submitted to a delegated group in error, California law requires the delegated group to automatically forward the misdirected claim to the health plan; however, submitting to the wrong entity will delay payment.
Practices that are experiencing other COVID-19 vaccine administration denials are encouraged to reach out to CMA at (888) 401-5911 or firstname.lastname@example.org.
For more information, see CMA’s COVID-19 Vaccine Toolkit for Medical Practices.