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 October 3, 2023, in accordance with the U.S. Food and Drug Administration’s (FDA’s) amended emergency use authorization for the Novavax COVID-19 vaccine, vaccine procedure code 91304 is now a benefit of Texas Medicaid, Healthy Texas Women (HTW), the Family Planning Program (FPP), the Children with Special Health Care Needs (CSHCN) Services Program, and Texas Health Steps.
Texas Medicaid, FPP, HTW, and Texas Health Steps Benefits
COVID-19 vaccine procedure code 91304 is a benefit of Texas Medicaid, FPP, and HTW for individuals who are 12 years of age or older. The procedure code may be reimbursed for the following provider types and places of service:
|Place of Service
|Physician, Physician Assistant, Nurse Practitioner, Clinical Nurse Specialist, Pharmacist, Certified Nurse Midwife, Registered Nurse, Licensed Midwife, Comprehensive Care Program (CCP), Nephrology (Hemodialysis, Renal Dialysis), Pharmacy
|Physician, Physician Assistant, Nurse Practitioner, Clinical Nurse Specialist, CCP Providers, Home Health Agency
|Hospital, Nephrology (Hemodialysis, Renal Dialysis), Renal Dialysis Facility
|Physician, Physician Assistant, Nurse Practitioner, Clinical Nurse Specialist, CCP Providers
Note: Texas Health Steps providers may be reimbursed for services rendered to clients who are 12 through 20 years of age in the office, home, outpatient hospital, and other location settings.
HTW and FPP providers may also be reimbursed for services rendered in family planning clinics.
CSHCN Services Program Benefits
Procedure code 91304 is a CSHCN Services Program benefit for the following provider types and places of service:
|Place of Service
|Physician, Physician Assistant, Advanced Practice Registered Nurse, Pharmacist
|Physician, Physician Assistant, Advanced Practice Registered Nurse
|Physician, Physician Group, Physician Assistant, Nurse Practitioner, Clinical Nurse Specialist
Important Vaccine Reminders
As of October 3, 2023, vaccine procedure code 91304 may be billed with vaccine administration procedure code 90480.
Vaccines administered to individuals eligible for the Vaccines for Children (VFC) program should come from VFC-provided stocks. COVID-19 vaccine products submitted for reimbursement will be processed as informational only when administered to individuals who are 6 months through 18 years of age.
Texas Medicaid, CSHCN, FPP, and HTW only cover vaccines that are authorized or approved by the FDA.
Note: Procedure code 91304 will be assigned an interim rate until expenditures are approved and a permanent rate is adopted by Texas Medicaid. We will notify providers 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, we 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. When the claims are reprocessed, providers may receive additional payment, which will be reflected on the Remittance and Status (R&S) Report.
For more information, call the Texas Medicaid & Healthcare Partnership (TMHP) Contact Center at 800-925-9126 or the TMHP-CSHCN Services Program Contact Center at 800-568-2413.