Provider Alert! COVID-19 Vaccine Administration Code 0004A Now a Medicaid Benefit

Date: October 18, 2021

Attention: Primary Care Providers

Effective Date: Dates of service on or after September 22, 2021

Providers should monitor the Texas Children’s Health Plan (TCHP) Provider Portal regularly for alerts and updates associated to the COVID-19 event.  TCHP reserves the right to update and/or change this information without prior notice due to the evolving nature of the COVID-19 event.

Call to action: Effective for dates of service on or after September 22, 2021, in accordance with the U.S. Food and Drug Administration (FDA) amendment to the Emergency Use Authorization (EUA), COVID-19 vaccine administration code 0004A is now a benefit of Medicaid. Procedure code 0004A, the booster dose of the Pfizer-BioNTech COVID-19 vaccine, should be administered at least six months after completion of the primary series of the Pfizer-BioNTech COVID-19 vaccine.

How this impacts providers: The FDA amendment to the EUA allows for the use of a single booster dose of the Pfizer-BioNTech COVID-19 vaccine, at least six months after completion of the primary series in:

• Individuals 65 years of age and older
• Long-term care facility residents
• Individuals 18 through 64 years of age with underlying medical conditions
• Individuals 18 through 64 years of age at increased risk for exposure and transmission due to occupational or institutional setting

Procedure code 0004A is a benefit for Medicaid for the following providers and places of service:

Procedure code M0201 (COVID-19 vaccine administration inside a patient’s home) can be billed in the Home setting with procedure code 0004A, as of September 22, 2021.

Providers may bill MCOs retroactively for COVID-19 vaccine administration code 0004A provided on or after September 22, 2021. MCOs must reprocess affected claims submitted with the procedure code and date of service on or after September 22, 2021. Providers are not required to appeal the claims unless they are denied for additional reasons after the claims reprocessing is complete.

Next steps for providers: Providers should share this communication with their staff.

If you have any questions, please email Provider Network Management at: providerrelations@texaschildrens.org.

For access to all provider alerts, log into:
www.thecheckup.org or www.texaschildrenshealthplan.org/for-providers