FQHC, RHC and Tribal FQHC providers may now submit claims for COVID-19 vaccine admin

April 19, 2022

As recently reported, the Centers for Medicare and Medicaid Services (CMS) recently approved the California Department of Health Care Services (DHCS) State Plan Amendment (SPA 21-0020) for coverage and reimbursement of COVID-19 vaccine administration in a vaccine-only encounter provided by Federally Qualified Health Centers (FQHC), Rural Health Centers (RHC) and Tribal RHCs.

The $67 per shot reimbursement rate approved by CMS is retroactive to November 2, 2020. While DHCS urged providers to hold claims until its systems were prepared to process claims under the SPA, DHCS has indicated it will automatically reprocess claims previously submitted. These claims will be automatically reprocessed at the lower of either the $67 rate or the billed charge if less than $67.

Providers who already billed Medi-Cal for the reimbursement of a COVID-19 vaccine-only encounters and entered a billed amount less than $67 can void and resubmit their claims electronically following the instructions in the Electronic Methods for Eligibility Transactions and Claim Submissions section of the Part 1 provider manual. Providers who elect to void and resubmit claims via hard copy, must request a void using the Claims Inquiry Form, and then resubmit the claim using the Appeal Form (90-1) once the provider has received confirmation of the void on their Remittance Advice Details.

DHCS has also indicated it intends to waive timely filing requirements for providers that appropriately held COVID-19 vaccine claims, as instructed. “Late” claims should be filed with delay reason code “10” and remarks indicating a COVID-19 vaccine was administered.

For COVID-19 vaccines that were administered during a qualifying office visit, FQHC, RHC, and Tribal FQHC providers are entitled to reimbursement at their individual PPS/APM rates. 

For more details and filing instructions, see the Medi-Cal News Flash.


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