COVID-19 Vaccination Update  

COVID-19 Vaccination Update  

On December 31, 2020 and January 12, 2021 we indicated our plans to update our system to allow Indian Health Services (Section 9), Federally Qualified Health Centers  (Section 31), Home Health (Section 40), Pharmacy (Section 80), and Rural Health Clinics (Section 103) providers who have entered into a CDC COVID-19 Vaccination Program Provider Agreement to submit claims for COVID-19 vaccine administration and product. Please read below for more information. 

Sections 9 (Indian Health Services), 31 (Federally Qualified Health Centers), and 103 (Rural Health Clinics)

We anticipate implementing system changes later this week to accept vaccination administration and product codes for these services. We will send a follow-up communication when billing is available.

Section 40, Home Health Services Providers

Effective January 28, 2021, our system has been updated and providers may submit claims retroactive to December 11, 2020. Please note that providers may need to resubmit denied claims for dates of service on or after December 11, 2020.

As previously communicated, effective December 11, 2020, we set reimbursement for vaccine administration at 100% of Medicare, which at the time the Centers for Medicare & Medicaid Services (CMS) had set as national rates. Soon after our announcement, CMS released regional Medicare rates. As a result, we have updated our rates to benchmark 100% of Medicare’s regional rates for Maine, effective January 1, 2021. Benchmarking the regional rate is our standard practice. This information can be found in the table below.

Please note that vaccine product codes 91300 (Pfizer-BioNTech) and 91301 (Moderna) have a $0 rate and must be billed with an SL modifier because COVID-19 vaccine product is supplied by the federal government.

COVID-19 Vaccine Administration Information, Effective 12/11/20 – 12/31/20
Vaccine Emergency Use Authorization (EUA)	Effective Dates	First Dose Administration Code	Second Dose Administration Code	First Dose Rate	Second Dose Rate
Pfizer-BioNTech	12/11/2020	0001A	0002A	$16.94	$28.39
Moderna	12/18/2020	0011A	0012A	$16.94	$28.39

 

COVID-19 Vaccine Administration Information, Effective 1/1/2021 – Current
Vaccine Emergency Use Authorization (EUA)	Effective Dates	First Dose Administration Code	Second Dose Administration Code	First Dose Rate	Second Dose Rate
Pfizer-BioNTech	12/11/2020	0001A	0002A	$15.87	$26.21
Moderna	12/18/2020	0011A	0012A	$15.87	$26.21

 

COVID-19 Vaccine Administration and Product Revenue Codes for Section 40, Home Health Services
MaineCare Section of Policy	COVID-19 Vaccine Product Revenue Code	COVID-19 Vaccine Administration Revenue Code
40: Home Health Services	0636	0771

 

Section 80, Pharmacy Services Provider Billing/Claims Guidance

Effective January 27, 2021, pharmacies may submit claims for reimbursement for COVID-19 vaccine administration and product retroactive to dates of service on or after January 1, 2021. We are currently updating our system so that we can also accept claims for dates of service from December 11, 2020 through December 31, 2020; we will notify you once the system can accept these claims.

Please note that MaineCare will not reimburse pharmacies for vaccine administration costs when they are being reimbursed through a separate arrangement with another payer.

Please refer to the most recent version of Section 6.2.1 of the NCPDP Emergency Preparedness Guidance (version 1.8) for examples and additional guidance on billing for reimbursement of a free product. In general, claims submitted for zero-cost vaccines should be submitted on a single B1/B3 billing transaction including the following data elements and values:

• Quantity Dispensed (442-E7) Moderna: NDC 80777027310 and 80777027399, value = 0.5 mL Pfizer: NDC 59267100001, 59267100002 and 59267100003, value= 0.3 mL
• Professional Service Code (440-E5) “MA” (Medication Administered)
• Submission Clarification Codes (SCC, 420-DK) First Dose=2, Second Dose=6
• Incentive Amount (administration fee, (438-E3) First Dose=$15.87 Second Dose=$26.21
• Basis of Cost (423-DN) Ingredient Cost (409- D9) “15” (free product or no associated cost) $0.00 or $0.01
• Gross Amount Due (430-DU) Include "Incentive Amount" submitted for the administration fee and zero cost of the vaccine

While the current Moderna and Pfizer-BioNTech vaccines require a series of two doses, potential future approved COVID-19 vaccines may require a single dose or a series of two doses to achieve expected efficacy. For a COVID-19 vaccine requiring a series of two doses, the initial dose administration rate will be $15.87, and the second dose administration rate will be $26.21. These rates recognize the costs involved in administering the vaccine, including the additional resources involved with required public health reporting, conducting important outreach and patient education, and spending additional time with patients answering any questions they may have about the vaccine.

Pharmacy providers administering COVID-19 vaccinations should instruct members receiving vaccines that require two doses to do the following:

• Use the same pharmacy for both vaccinations
• Receive the second dose on the date specified by the manufacturer’s product labeling

Two-Dose Vaccines: The Submission Clarification Code (420-DK) field should be used to differentiate which dose is being administered to allow proper reimbursement. This guidance applies regardless of whether the same provider or different providers administer the series of doses.

Single-Dose Vaccines: No Submission Clarification Code is required for a single-dose product, Incentive Amount=$26.21.

For questions, please contact the Change Healthcare Pharmacy Help Desk at 1-888-420-9711. MaineCare providers can also send inquiries via email to PBA_helpdesk@changehealthcare.com.

 

Member Eligibility for Vaccine Coverage

As a reminder, the COVID-19 vaccine is a covered benefit for all full MaineCare members, for members who are covered through MaineCare’s Special Benefits HIV Waiver, and for members who are in the pregnancy presumptive eligibility category (also known as “pregnancy-related coverage”). The vaccine is available to these members at no cost to them. Providers cannot charge individuals for the COVID-19 vaccination, regardless of insurance status.

Providers who administer a licensed or authorized COVID-19 vaccine to uninsured individuals or those enrolled in MaineCare with certain limited benefits (family planning services, family planning presumptive eligibility, emergency MaineCare, and prisoner inpatient) should request reimbursement through the federal Health Resources & Services Administration (HRSA). For more information on the process and the availability of funds, please visit HRSA’s website. For more guidance about vaccine coverage for uninsured individuals or those with limited benefits, please see CMS’ website.