Medi-Cal not ready to process claims for new COVID-19 vaccine; Physicians should NOT hold claims

October 04, 2023

On September 11, 2023, the United States Food and Drug Administration (FDA) authorized updated COVID-19 vaccines to target the currently circulating Omicron XBB.1.5 variant. As of September 12, 2023, the Centers for Disease Control and Prevention (CDC) recommends the 2023-2024 updated COVID-19 vaccines for everyone six months of age and older to protect against serious illness from COVID-19.

Additionally, with the updated vaccine, the federal government is no longer purchasing COVID-19 vaccines, requiring physicians to buy and bill as they do other vaccines.

Effective for dates of service on or after September 11, 2023, the vaccine and administration fee for the commercialized COVID-19 vaccines is reimbursable as a medical benefit under Medi-Cal.

According to the California Department of Health Care Services (DHCS), it has not yet completed the necessary system and operational changes to allow for adjudication of claims for the commercial COVID-19 vaccines. Practices should NOT, however, hold claims. DHCS has indicated it will go back and automatically reprocess claims through an Erroneous Payment Correction (EPC) back to September 12, 2023, once the system is updated.

Reimbursement for fee-for-service Medi-Cal and Medi-Cal managed care plan claims will be at the Medicare rate. Reimbursement for vaccine administration varies depending on the geographic area, but is approximately $40, which is what it was for the prior bivalent vaccine.

DHCS will continue to carve out the COVID-19 vaccines and administration from the managed care plans until at least December 31, 2024. This means that physicians should continue to bill Medi-Cal directly using the patient’s Medi-Cal beneficiary ID number, rather than the Medi-Cal managed care plan ID.  

For individuals 6 months to 18 years of age, the vaccines are covered through the Vaccines For Children program.

For more information, see the 2023-2024 Commercialized COVID-19 Vaccines Medi-Cal Policy Update.


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