Update: Janssen (Johnson & Johnson), Moderna COVID-19 and Pfizer COVID-19 Vaccine Boosters
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The purpose of this bulletin is to inform providers that DMAS and all managed care organizations (MCOs) will cover Janssen (Johnson & Johnson), Pfizer-BioNTech and Moderna COVID-19 vaccine booster doses for full benefit Medicaid and FAMIS members 18 years and older, consistent with recently amended FDA Emergency Use Authorizations (EUAs). In accordance with the American Rescue Plan Act of 2021 (ARPA), this coverage will be extended to Plan First members “until the last day of the first calendar quarter that begins one year after the end of the federal public health emergency.” Further contact information is included at the bottom of this document. For prior memos outlining DMAS COVID-19 vaccination coverage, please visit: https://www.virginiamedicaid.dmas.virginia.gov/wps/portal/MedicaidMemostoProviders.
Billing: Janssen (Johnson & Johnson) Vaccine Booster Dose
In light of the Federal Drug Administration’s (FDA) amended Emergency Use Authorization (EUA) authorizing administration of a booster dose of the Janssen (Johnson & Johnson) COVID-19 vaccine, the following vaccine administration code will be covered for fee-for-service (FFS) and MCO members with dates of service on and after 10/20/2021, with FFS reimbursement rates listed below:
- 0034A ($40.00): Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, DNA, spike protein, adenovirus type 26 (Ad26) vector, preservative free, 5x1010 viral particles/0.5 mL dosage; booster dose
Billing: Moderna Vaccine Booster Dose
In light of the FDA’s amended EUA authorizing administration of a booster dose of the Moderna COVID-19 vaccine, the following COVID-19 vaccine booster dose and administration codes will be covered for FFS and MCO members with dates of service on and after 10/20/2021, with FFS reimbursement rates listed below:
- 91306 ($0.01): Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 50 mcg/0.25 mL dosage, for intramuscular use
- 0064A ($40.00): Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 50 mcg/0.25 mL dosage, booster dose
Eligibility for Vaccine Boosters & “Mix & Match” Flexibilities
Effective the dates listed above, individuals eligible to receive a booster are those who are at least 18 years of age and:
- Are at least 2 months after completion of the Janssen (Johnson & Johnson) vaccine, OR
- Are at least 6 months after completion of the primary two-part Pfizer-BioNTech or Moderna vaccine series
Individuals eligible to receive a booster may receive a booster dose from any of the three approved COVID-19 vaccines (Janssen [Johnson & Johnson], Pfizer-BioNTech or Moderna) according to the conditions above, irrespective of which primary vaccine series they initially completed.
Of note, booster doses are not the same as the third dose authorized for certain immunocompromised patients. DMAS and managed care policies on third dose coverage is described in the October 19, 2021 Medicaid Memo “Coverage of Additional COVID Vaccine Dose for Certain Immunocompromised Individuals”.
Prior authorization is not required for any booster dose for either FFS or MCO members.
Pharmacy providers should use Submission Clarification Code = 7 (medically necessary) to indicate the administration of a booster dose of COVID-19 vaccine for eligible FFS Members. Basis of Cost Determination ‘15’ (free product or no associated cost) and Professional Service Code ‘MA’ (Medication Administered) still apply.
An updated summary of the covered medical billing codes and FFS reimbursement rates currently available for COVID-19 vaccination for full benefit Medicaid and FAMIS populations indefinitely (including FFS and MCO members), as well as Plan First members until the last day of the first calendar quarter that begins one year after the end of the federal public health emergency, is included below. CMS continues to anticipate that, at this time, providers will not incur a cost for vaccine products (CPT 91300, 91301, 91303, 91306, 91307). Providers should not bill for vaccine products if they received it for free.
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Billing Code |
Description |
Reimbursement Rate |
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91300
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Severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) (Coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 30 mcg/0.3mL dosage, diluent reconstituted, for intramuscular use |
$0.01 |
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0001A |
Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) (Coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 30 mcg/0.3mL dosage, diluent reconstituted; first dose |
$40.00 |
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0002A |
Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) (Coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 30 mcg/0.3mL dosage, diluent reconstituted; second dose |
$40.00 |
|
0003A |
Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 30 mcg/0.3 mL dosage, diluent reconstituted; third dose |
$40.00 |
|
0004A |
Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 30 mcg/0.3 mL dosage, diluent reconstituted; booster dose |
$40.00 |
|
91301 |
Severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) (Coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 100 mcg/0.5mL dosage, for intramuscular use |
$0.01 |
|
0011A |
Immunization administration by intramuscular injection of Severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) (Coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 100 mcg/0.5mL dosage; first dose |
$40.00 |
|
0012A |
Immunization administration by intramuscular injection of Severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) (Coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 100 mcg/0.5mL dosage; second dose |
$40.00 |
|
0013A |
Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 100 mcg/0.5 mL dosage; third dose |
$40.00 |
|
91303 |
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, DNA, spike protein, adenovirus type 26 (Ad26) vector, preservative free, 5x1010. viral particles/0.5mL dosage, for intramuscular use |
$0.01 |
|
0031A |
Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, DNA, spike protein, adenovirus type 26 (Ad26) vector, preservative free, 5x1010 viral particles/0.5mL dosage, single dose |
$40.00 |
|
0034A |
Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, DNA, spike protein, adenovirus type 26 (Ad26) vector, preservative free, 5x1010 viral particles/0.5 mL dosage; booster dose |
$40.00 |
|
91306 |
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 50 mcg/0.25 mL dosage, for intramuscular use |
$0.01 |
|
0064A |
Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 50 mcg/0.25 mL dosage, booster dose |
$40.00 |
|
91307* |
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 10 mcg/0.2 mL dosage, diluent reconstituted, tris-sucrose formulation, for intramuscular use |
$0.01 |
|
0071A* |
Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 10 mcg/0.2 mL dosage, diluent reconstituted, tris-sucrose formulation; first dose |
$40.00 |
|
0072A* |
Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 10 mcg/0.2 mL dosage, diluent reconstituted, tris-sucrose formulation; second dose |
$40.00 |
|
M0201* |
Covid-19 vaccine administration inside a patient's home; reported only once per individual home per date of service when only Covid-19 vaccine administration is performed at the patient's home |
$35.00 |
* Covered for full benefit Medicaid and FAMIS populations but not Plan First members.
Any questions on FFS pharmacy claims processing may be directed to the Magellan pharmacy call center 7 days a week 24 hours per day at 800-932-6648. Any questions on MCO pharmacy claims processing, or medical coverage for members enrolled in managed care organizations, may be directed to managed care points of contact summarized below.
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PROVIDER CONTACT INFORMATION & RESOURCES |
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Virginia Medicaid Web Portal Automated Response System (ARS) Member eligibility, claims status, payment status, service limits, service authorization status, and remittance advice. |
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Medicall (Audio Response System) Member eligibility, claims status, payment status, service limits, service authorization status, and remittance advice. |
1-800-884-9730 or 1-800-772-9996 |
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KEPRO Service authorization information for fee-for-service members.
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Provider Appeals DMAS launched an appeals portal in 2021. You can use this portal to file appeals and track the status of your appeals. Visit the website listed for appeal resources and to register for the portal. |
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Managed Care Programs Medallion 4.0, Commonwealth Coordinated Care Plus (CCC Plus), and Program of All-Inclusive Care for the Elderly (PACE). In order to be reimbursed for services provided to a managed care enrolled individual, providers must follow their respective contract with the managed care plan/PACE provider. The managed care plan may utilize different guidelines than those described for Medicaid fee-for-service individuals. |
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Medallion 4.0 |
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CCC Plus |
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PACE |
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Magellan Behavioral Health Behavioral Health Services Administrator, check eligibility, claim status, service limits, and service authorizations for fee-for-service members. |
www.MagellanHealth.com/Provider For credentialing and behavioral health service information, visit: www.magellanofvirginia.com, email: VAProviderQuestions@MagellanHealth.com,or Call: 1-800-424-4046 |
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Provider HELPLINE Monday–Friday 8:00 a.m.-5:00 p.m. For provider use only, have Medicaid Provider ID Number available. |
1-804-786-6273 1-800-552-8627 |
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Aetna Better Health of Virginia |
www.aetnabetterhealth.com/Virginia 1-800-279-1878 |
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Anthem HealthKeepers Plus |
1-800-901-0020 |
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Molina Complete Care
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1-800-424-4524 (CCC+) 1-800-424-4518 (M4) |
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Optima Family Care |
1-800-881-2166 www.optimahealth.com/medicaid |
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United Healthcare |
and www.myuhc.com/communityplan 1-844-752-9434, TTY 711 |
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Virginia Premier |
1-800-727-7536 (TTY: 711), www.virginiapremier.com |