Coverage of Additional COVID Vaccine Dose for Certain Immunocompromised Individuals
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The purpose of this memorandum is to inform providers that DMAS and all managed care organizations (MCOs) will cover two (2) new vaccine administration codes for a third COVID vaccine dose for certain immunocompromised individuals for all full benefit Medicaid and FAMIS populations. In accordance with American Rescue Plan Act of 2021, these two administration codes will also be covered for 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.
This memo builds on the previous Medicaid Memos, “Coverage of COVID-19 Vaccine Administration” (dated December 11, 2020), “Pharmacy Procedure for COVID-19 Vaccine” (dated January 5, 2021), and “Coverage of COVID-19 Vaccine Administration for Plan First” (dated June 28, 2021). These memos communicated coverage of one and two-dose COVID vaccination series for various DMAS populations, effective December 10, 2020, January 5, 2021 and March 11, 2021 onwards, respectively.
In light of the Federal Drug Administration’s (FDA) amended Emergency Use Authorization (EUA) to authorize a third dose of the Pfizer-BioNTech COVID-19 Vaccine and the Moderna COVID-19 Vaccine for certain immunocompromised individuals, the following two COVID-19 vaccine administration codes will be covered for FFS and MCO members with dates of service on and after August 12, 2021, with FFS reimbursement rates listed below:
- 0003A ($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, 30 mcg/0.3 mL dosage, diluent reconstituted; third dose
- 0013A ($40.00): 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
Providers should reference CDC guidance (see https://www.cdc.gov/coronavirus/2019-ncov/vaccines/recommendations/immuno.html) when identifying certain immunocompromised patients appropriate for a third vaccine dose as well as when determining the appropriate timing of administering a third vaccine dose. Of note, this additional dose for certain immunocompromised patients is not the same as a booster dose, given to people when the immune response to a primary vaccine series may have waned over time.
Prior authorization is not required for either FFS or MCO members.
Pharmacy providers should use Submission Clarification Code = 7 (medically necessary) to indicate the administration of a third 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. 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.
An updated summary of the covered CPT and HCPCS codes 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:
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CPT 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 |
|
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 |
|
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 |
|
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 |
SARSCOV2 VAC AD26 .5ML Janssen Covid-19 Vaccine |
$0.01 |
|
0031A |
ADM SARSCOV2 VAC AD26 .5ML Janssen Covid-19 Vaccine Admin. |
$40.00 |
CMS continues to anticipate that, at this time, providers will not incur a cost for vaccine products (CPT 91300, 91301, 91303). Providers should not bill for vaccine products if they received it for free.
For questions on coverage for members enrolled in a managed care organization, refer to the contact information listed 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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Magellan Complete Care of Virginia |
1-800-424-4518 (TTY 711) or 1-800-643-2273 |
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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 |