November 22, 2021
Shortly after federal approval of the COVID-19 vaccine for children age 5-11, the California Medical Association (CMA) began receiving reports that clearinghouse Office Ally was rejecting the claims for 5-11-year-olds with a message code stating the CPT codes were invalid.
CMA brought the issue to Office Ally and urged them to correct the issue as soon as possible.
Unfortunately, this is not an isolated issue. Since the COVID-19 vaccines were approved in early 2020, some payors have 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 are eventually 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.
CMA sent letters to the California Department of Managed Health Care (DMHC) and the California Department of Insurance (CDI) asking the agencies to encourage payors to proactively prepare their claims processing systems to correctly process COVID-19 vaccine administration claims from day one for newly eligible populations, particularly for the anticipated approval of the 5–11-year-old pediatric vaccine. DMHC and CDI both subsequently did send out notices encouraging payors to update their systems without delay so physicians are not faced with unnecessary delays as California looks to vaccinate 3.5 million newly eligible kids aged 5-11 over the next couple of months.
Within a few days of CMA raising the issue, OA reported that it has corrected the problem effective Tuesday, November 16, 2021, so physicians using OA as a clearinghouse can resume electronically submitting their COVID-19 vaccine claims for 5-11 year olds.