Effective with date of service Aug. 31, 2022, the NC Medicaid and NC Health Choice programs cover Pfizer-BioNTech COVID-19 Vaccine, Bivalent (Original and Omicron BA.4/BA.5) - 12 years of age and older (N/A) for use in the Physician Administered Drug Program (PADP) when billed with HCPCS code 91312 - Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, bivalent spike protein, preservative free, 30 mcg/0.3 mL dosage, tris-sucrose formulation, for intramuscular use.
A single booster dose (0.3 mL) of Pfizer-BioNTech COVID-19 Vaccine, Bivalent may be administered at least two months after completion of primary vaccination or receipt of the most recent booster dose with any authorized or approved monovalent COVID-19 vaccine.
Effective with date of service Aug. 31, 2022, the NC Medicaid and NC Health Choice programs cover Moderna COVID-19 Vaccine, Bivalent (Original and Omicron BA.4/BA.5) - Booster Dose (N/A) for use in the Physician Administered Drug Program (PADP) when billed with HCPCS code 91313 - Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, bivalent, preservative free, 50 mcg/0.5 mL dosage, for intramuscular use.
A single booster dose (0.5 mL) of Moderna COVID-19 Vaccine, Bivalent may be administered at least two months after completion of primary vaccination or receipt of the most recent booster dose with any authorized or approved monovalent COVID-19 vaccine.
For Medicaid and NC Health Choice Billing
- The ICD-10-CM diagnosis code(s) required for billing is/are: Z23 - Encounter for immunization
- Providers must bill with the correct HCPCS codes as listed above
- One Medicaid and NC Health Choice unit of coverage is:
- 0.3 mL for 91312 Pfizer-BioNTech COVID-19 Vaccine, Bivalent
- 0.5 mL for 91313 Moderna COVID -19 Bivalent Vaccine
- The maximum reimbursement rate per unit is: $0.00 for COVID vaccines
- Providers must bill 11-digit NDCs and appropriate NDC units.
- The NDCs for 91312 Pfizer-BioNTech COVID -19 Vaccine, Bivalent are: 59267-1404-01, 59267-1404-02, 59267-0304-01, 59267-0304-02
- The NDCs for 91313 Moderna COVID -19 Bivalent Vaccine are: 80777-0282-05, 80777-0282-99
- The following are the codes for administration:
- 0124A - Pfizer-BioNTech COVID -19 Vaccine, Bivalent (Ready to Use) Administration – Booster
- 0134A - Moderna COVID -19 Bivalent Vaccine (Dark Blue Cap) 50MCG/0.5ML Administration – Booster
Important Claims Information
- NC Medicaid and NC Health Choice will reimburse at the Medicare-approved COVID-19 vaccination administration rate of $65
- Claims must have appropriate NDCs that correspond to the vaccine used for administration and corresponding CPT code.
- Claims must contain both administration codes and vaccine codes to pay
- Vaccine codes should be reported as $0.00
- Copays may not be charged for COVID-19 immunization or administrations
- COVID-19 vaccines are exempt from the Vaccines For Children (VFC) program
- TJ modifier should be appended to all NC Health Choice claims (through age 18)
- EP modifier should be appended to all non-NC Health Choice (only NC Medicaid beneficiaries) younger than age 21
- CG modifier should be appended to ALL COVID-19 vaccine AND administration claims submitted by a pharmacy participating in the immunization program.
The Statewide Standing Order U.S. Food and Drug Administration (FDA) Emergency Use Authorization (EUA) Moderna Bivalent Booster (18+) and Pfizer Bivalent Booster (12+) are now published online and available.
- Statewide Standing Order for FDA Authorized bivalent (original and Omicron BA.4/BA.5) Pfizer-BioNTech COVID-19 Vaccine Administration in Patients 12 Years and Older (Sept. 2, 2022)
- Statewide Standing Order for FDA Authorized bivalent (original and Omicron BA.4/BA.5) Moderna COVID-19 Vaccine Administration in Patients 18 Years and Older (Sept. 2, 2022)
With these authorizations, the monovalent Mrna COVID-19 vaccines are not authorized as booster doses for individuals 12 years of age and older.
Resources
- Coronavirus (COVID-19) Update: FDA Authorizes Moderna, Pfizer-BioNTech Bivalent COVID-19 Vaccines for Use as a Booster Dose
- Moderna fact sheet for health care providers administering vaccine - EUA
- Pfizer fact sheet for health care providers administering vaccine - EUA
Contact
NCTracks Call Center: 800-688-6696