COVID-19 Vaccine Payment Bulletin

The PA Department of Human Services (DHS) has finally released the long-awaited Medical Assistance Bulletin outlining payment for administration of COVID-19 vaccine during a vaccine-only visit in which no other services are provided on the same date. The bulletin announces DHS is implementing an alternative payment methodology (APM):

  1. To pay the MA Program Fee Schedule rate for the administration of the vaccine on or after Dec. 1, 2020
  2. To pay the enhanced MA Program Fee Schedule rate for the administration of the vaccine to homebound MA beneficiaries during a vaccine-only visit for dates of service on or after April 1, 2021

It is important to note that the bulletin applies to fee-for-service only; providers rendering services to MA beneficiaries in the managed care delivery system (HealthChoices) must utilize the COVID-19 vaccine administration codes for DHS tracking purposes but must contact the managed care organization (MCO) with billing questions. The bulletin outlines the procedure codes for administration of the vaccine, which are distinct to each COVID vaccine and the specific dose in the required schedule. In order to bill under this new APM, a request to opt in to the APM as of Dec. 1, 2020, must be submitted by the FQHC/RHC chief financial officer (CFO) via email to DHS at within 30 days of issuance of the bulletin (by March 26, 2022) and must include both the FQHC/RHC nine-digit service location number for which the opt-in is to be applied. The email should indicate the FQHC/RHC is accepting the APM. Claims submitted within 60 days of the issuance of the bulletin (April 25, 2022) will not be subject to the time frames for submission of claims in 55 Pa. Code §1101.63(b). Read the full bulletin.