Update to Coronavirus Disease 2019 (COVID-19) Vaccine Administration Coverage to include Pediatric Coverage, Updated Booster Eligibility

The Centers for Disease Control and Prevention (CDC) has recently updated its recommendations regarding who is eligible to receive a COVID-19 vaccine to include children ages 5-11 years. The CDC has also updated its recommendations on who is eligible to receive a COVID-19 vaccine booster shot. The South Carolina Department of Health and Human Services (SCDHHS) will reimburse enrolled providers for the administration of COVID-19 vaccines, including additional doses of the COVID-19 vaccine consistent with the CDC’s guidance. The CDC is maintaining updated guidance on COVID-19 vaccines for specific groups of people, including guidance based on age, on its website. The CDC is also maintaining updated guidance on COVID-19 vaccine booster shot eligibility criteria on its website.

SCDHHS will reimburse for dates of service based on the effective dates for vaccine administration established by the Centers for Medicare and Medicaid Services (CMS).

SCDHHS will adopt the billing codes, reimbursement rates and effective dates published by 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
0004A Pfizer-BioNTech COVID-19 Vaccine Administration – Booster
0071A Pfizer-BioNTech COVID-19 Pediatric Vaccine Administration – First dose
0072A Pfizer-BioNTech COVID-19 Pediatric Vaccine Administration – Second 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
0064A Moderna COVID-19 Vaccine (Low Dose) Administration – Booster
0031A Janssen COVID-19 Vaccine Administration – First Dose
0034A Janssen COVID-19 Vaccine Administration – Booster

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

The billing and eligibility guidance from the agency’s Dec. 22, 2020, Medicaid bulletin remain in effect. As a reminder, for Healthy Connections 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 Healthy Connections Medicaid members should be submitted to SCDHHS in the customary fashion.

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 Food and Drug Administration 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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