Coronavirus Disease 2019 (COVID-19) Third Dose of Vaccine Administration Coverage

The South Carolina Department of Health and Human Services (SCDHHS) will reimburse for the administration of additional doses of the COVID-19 vaccine consistent with the updated emergency use authorization issued by the U.S. Food and Drug Administration (FDA) and the recommendations of the Centers for Disease Control and Prevention (CDC). Currently, the FDA has approved an additional dose of both the Pfizer-BioNTech COVID-19 vaccine and the Moderna COVID-19 vaccine for immunocompromised individuals. The CDC has further defined individuals who fit these criteria through guidelines available on its website .

SCDHHS will adopt the billing codes, reimbursement rates and effective dates published by the Centers for Medicare and Medicaid Services (CMS) for Medicare Part B coverage, which are  available on CMS’ website . The current administration codes are included in the table below. Please note, these codes are subject to change without notice.

CPT Code

Description

0001A

Pfizer-Biontech COVID-19 Vaccine Administration – First Dose

0002A

Pfizer-Biontech COVID-19 Vaccine Administration – Second Dose

0003A

Pfizer-Biontech COVID-19 Vaccine Administration – Third Dose

0011A

Moderna COVID-19 Vaccine Administration – First Dose

0012A

Moderna COVID-19 Vaccine Administration – Second Dose

0013A

Moderna COVID-19 Vaccine Administration – Third Dose

0031A

Janssen COVID-19 Administration- Single Dose

 

SCDHHS will reimburse COVID-19 vaccine administration as a “bill-above” service for Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs).

SCDHHS will reimburse for dates of service based on the effective dates for vaccine administration  established by CMS .  

The billing and eligibility guidance from the agency’s Dec. 22, 2020, Medicaid bulletin remain in effect. As a reminder, for Medicaid members enrolled in a managed care organization (MCO), providers should bill the appropriate MCO for COVID-19 vaccine administration. Claims for fee-for-service Medicaid members should be submitted to SCDHHS in the customary fashion.

SCDHHS will provide additional information as the approach to vaccine and vaccine administration financing changes. The agency will also update guidance regarding coverage of additional doses of COVID-19 vaccines as they are approved for more individuals.

The information contained in this bulletin is intended to provide guidance on vaccine administration coverage during the initial period of availability when the vaccine is being federally purchased and when administered to Healthy Connections Medicaid members, without patient cost-sharing, who fit the criteria defined by the FDA and CDC.

Providers should direct any questions related to this bulletin to the Provider Service Center at (888) 289-0709. The Provider Service Center’s hours of operations are 7:30 a.m.-5 p.m. Monday-Thursday and 8:30 a.m.-5 p.m. Friday.

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