DMHC urges payors to proactively prepare for pediatric COVID-19 vaccine admin claims

November 02, 2021

The California Department of Managed Health Care (DMHC) recently issued an all-plan letter (APL 21-023) encouraging plans to take steps now so they can proactively prepare for the administration of COVID-19 vaccines to children between age 5 to 11 years as soon as the vaccine is approved for use in that population.

DMHC anticipates the Centers for Disease Control and Prevention (CDC) will issue an Emergency Use Authorization for the COVID-19 vaccine for children ages 5 to 11 in the coming days. DMHC told plans they should take immediate steps, if they have not done so already, to ensure eligible pediatric plan enrollees can access the COVID-19 vaccine as soon as the CDC authorizes its use.

Such steps include preparing their claims processing systems so they can correctly process COVID-19 vaccine administration claims for children ages 5 to 11 years. Doing so will help avoid delays in reimbursement to providers that some providers reported experiencing when the COVID-19 vaccine was first approved for enrollees twelve and older.

This APL was issued in response to letters sent last week by the California Medical Association (CMA) to DMHC and the California Department of Insurance (CDI) asking that the agencies encourage payors to proactively prepare their claims processing systems. 

Some payors have thus far been slow to update their systems to process vaccine administration claims correctly, resulting in claim denials and leaving physicians with no reimbursement for the services provided to newly eligible patients. While the problems have eventually been identified and corrected, the lack of preparedness creates administrative and financial barriers for the physician community to administer COVID-19 vaccines. Addressing these barriers is critical to getting more individuals vaccinated.


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