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COVID-19 Convalescent Plasma Is a Benefit Effective December 28, 2021

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Note: Texas Medicaid managed care organizations (MCOs) must provide all medically necessary, Medicaid-covered services to eligible clients. Administrative procedures such as prior authorization, precertification, referrals, and claims/encounter data filing may differ from traditional Medicaid (fee-for-service) and from MCO to MCO. Providers should contact the client's specific MCO for details.

Effective April 1, 2022, COVID-19 convalescent plasma procedure code C9507 is a benefit of Texas Medicaid and the Children with Special Health Care Needs (CSHCN) Services Program for dates of service on or after December 28, 2021, as follows:

Place of Service

Provider Type

Diagnosis Restriction

Outpatient hospital

Ambulatory surgical center and hospital providers

U071

Benefit Criteria

The Food and Drug Administration’s emergency use authorization (EUA) for COVID-19 convalescent plasma is for the treatment of hospitalized patients (inpatient or outpatient) with impaired immunity.

Procedure code C9507 is a benefit for clients of all ages, including pregnant women and children who meet EUA criteria.

Note: Prior authorization is not required for procedure code C9507.

Providers should follow the National Institutes of Health COVID-19 Treatment Guidelines for convalescent plasma, which can be found on the following webpage: NIH COVID convalescent plasma guidelines

Documentation Requirements

Documentation of medical necessity and impaired immunity must be maintained in the client’s medical record for each unit infused.

Services may be subject to retrospective review.

Reprocessing Claims

Affected claims with dates of service on or after December 28, 2021, will be reprocessed, and providers may receive additional payment, which will be reflected on future Remittance and Status (R&S) Reports. Providers are not required to appeal the claims unless the claims are denied for additional reasons after reprocessing is complete.

For more information, call the TMHP Contact Center at 800-925-9126 or the TMHP-CSHCN Services Program Contact Center at 800-568-2413.