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RSV Monoclonal Antibody Nirsevimab Is a Benefit of CSHCN Services Program

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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 October 2, 2023, respiratory syncytial virus (RSV) monoclonal antibody nirsevimab (procedure codes 90380 and 90381) and its administration are benefits of the Children with Special Health Care Needs (CSHCN) Services Program.

Administration of nirsevimab on dates of service October 2, 2023, through October 5, 2023, may be reimbursed using existing procedure code 96372.

Effective October 6, 2023, nirsevimab administration procedure codes 96380 and 96381 may be reimbursed for the following provider types and places of service:

Place of ServiceProvider Type
OfficePhysician, Physician Assistant, Nurse Practitioner, Clinical Nurse Specialist
Outpatient HospitalHospital Providers

Limitations

Procedure codes 96380 and 96381 are limited to two services per lifetime and should never be billed together. The services must be billed with either procedure code 90380 or 90381.

Reprocessing

Affected claims that are submitted with dates of service on or after October 2, 2023, will be reprocessed. Providers may receive additional payment, which will be reflected on future Remittance and Status (R&S) Reports.

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