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COVID-19 Vaccine Administration Procedure Code 0174A Is Now a Benefit

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Note: Texas Medicaid managed care organizations (MCOs) must provide all medically necessary, Medicaid-covered services to Medicaid members who are enrolled in their MCO. Administrative procedures, such as prior authorization, precertification, referrals, and claims and encounter data filing, may differ from traditional Medicaid (fee-for-service) and from MCO to MCO. Providers should contact the member’s specific MCO for details.

Effective for dates of service on or after March 14, 2023, in accordance with the U.S. Food and Drug Administration’s amended Emergency Use Authorization, COVID-19 vaccine administration procedure code 0174A for the administration of the Pfizer-BioNTech COVID-19 vaccine booster is now a benefit of Texas Medicaid and the Children with Special Health Care Needs (CSHCN) Services Program for individuals 6 months through 4 years of age.

Vaccine procedure code 91317 will continue to be informational only while the vaccine is distributed to providers free of charge.

Procedure code 0174A is a Medicaid benefit for the following provider types and places of service:

Place of Service

Provider Type

Office

Physician Assistant (PA), Nurse Practitioner (NP), Clinical Nurse Specialist (CNS), Physician, Pharmacist, Certified Nurse Midwife (CNM), Federally Qualified Health Centers (FQHCs), Nephrology (Hemodialysis, Renal Dialysis), Rural Health Clinics (RHCs), Pharmacy

Home

PA, NP, CNS, Physician, Home Health Agency, Comprehensive Care Program (CCP) Provider

Outpatient hospitals

FQHCs, Hospitals, Nephrology (Hemodialysis, Renal Dialysis), Renal Dialysis Facility, RHCs

Other locations

PA, NP, CNS, Physician, FQHCs, CCP Provider, RHCs

Procedure code 0174A is a CSHCN Services Program benefit for the following provider types and places of service:

Place of Service

Provider Type

Office

PA, NP, CNS, Physician, Pharmacist, FQHCs, Nephrology (Hemodialysis, Renal Dialysis), RHCs, Pharmacy

Home

PA, NP, CNS, Physician, Home Health Agency, CCP Provider

Outpatient hospitals

FQHCs, Hospitals, Nephrology (Hemodialysis, Renal Dialysis), Renal Dialysis Facility, RHCs

Other locations

PA, NP, CNS, Physician, FQHCs, CCP Provider, RHCs

As of March 14, 2023, procedure code M0201 (COVID-19 vaccine administration inside a patient’s home) can be billed in the home setting with procedure code 0174A for individuals 6 months through 4 years of age.

Note: Procedure code 0174A will be assigned an interim rate until expenditures are approved and a permanent rate is adopted by Texas Medicaid. Providers will be notified of the permanent rate in a future article.

Services provided before the interim rate is assigned will receive the following explanation of benefits (EOB) 02008 notification, “This procedure code has been approved as a benefit pending the approval of expenditures.

Providers will be notified of the effective dates of service in a future notification if expenditures are approved.” Once expenditures are approved, TMHP will automatically reprocess the affected claims. Providers are not required to appeal the claims unless they are denied for other reasons after the claims reprocessing is complete.

Providers interested in enrolling as COVID-19 vaccinators should visit https://www.dshs.texas.gov/coronavirus/immunize/provider-information.aspx.

For more information, call the TMHP Contact Center at 1-800-925-9126 or the TMHP-CSHCN Services Program Contact Center at 1-800-568-2413.