Effective with date of service Aug. 31, 2022, Medicaid and NC Health Choice programs cover Pfizer-BioNTech COVID-19 Vaccine, Bivalent (Original and Omicron BA.4/BA.5) - 5 years through 11 years (N/A) for use in the Physician Administered Drug Program (PADP) when billed with HCPCS code 91315 - Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, bivalent spike protein, preservative free, 10 mcg/0.2 mL dosage, diluent reconstituted, tris-sucrose formulation, for intramuscular use.
The U.S. Food and Drug Administration (FDA) has issued an Emergency Use Authorization (EUA) to permit the emergency use of the unapproved product, Pfizer-BioNTech COVID-19 Vaccine, Bivalent (Original and Omicron BA.4/BA.5) for active immunization to prevent COVID-19 in individuals 5 years of age through 11 years of age.
A single booster dose (0.2 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. See full prescribing information for further detail.
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 vaccine HCPCS code: 91315 - Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, bivalent spike protein, preservative free, 10 mcg/0.2 mL dosage, diluent reconstituted, tris-sucrose formulation, for intramuscular use
- Providers must bill with administration HCPCS code: 0154A - Pfizer-BioNTech Covid-19 Vaccine, Bivalent Administration – Booster
- One Medicaid and NC Health Choice unit of coverage is: 0.2 mL (1 dose) of 91315
- Providers must bill 11-digit NDCs and appropriate NDC units. The NDCs is/are: 59267-0565-01, 59267-0565-02
Important Claims Information
- Medicaid and NC Health Choice will reimburse at the Medicare-approved COVID-19 vaccination administration rate at $65
- Claims must contain both administration codes and vaccine codes to pay, and NDC that corresponds to the vaccine administered
- Vaccine codes should be reported as $0.00
- NC Medicaid and NC Health Choice do not allow copays to be charged for COVID-19 immunization or administrations
- COVID-19 vaccines are exempt from the Vaccines For Children (VFC) program
- Pharmacies have been given authorization to administer any COVID-19 vaccine as per FDA/EUA age approval to Medicaid and/or NC Health Choice beneficiary. All other vaccines (non-COVID-19 vaccines), that are approved by the NC Board of Pharmacy to be administered by a pharmacist, are only permissible to be administered at a pharmacy for Medicaid beneficiaries aged 19 and older.
- EP modifier should be appended to all non-NC Health Choice (only Medicaid beneficiaries) younger than age 21
- TJ modifier should be appended to all NC Health Choice vaccine claims
- CG modifier should be appended to ALL COVID-19 vaccine AND administration claims submitted by a pharmacy participating in the immunization program
Contact
NCTracks Call Center: 800-688-6696