COVID-19 Vaccine Guidance

Last update: January 8, 2021, 10:45 a.m. CDT

Keeping you up to date on the latest developments for a COVID-19 vaccine is our top priority. We’re closely monitoring COVID-19 vaccine updates from state and federal governments and health care agencies. We will continue to post on this page as new information becomes available. 

Click here for more information from the U.S. Food and Drug Administration (FDA) on emergency use authorization (EUA) of the COVID-19 vaccine.

New! COVID-19 Vaccine Reimbursement Overview

This course provides information on COVID-19 administration, billing, reimbursement and resources. It may be most beneficial to CDC COVID-19 vaccination program providers. 

The cost of COVID-19 FDA-authorized vaccine serums will initially be paid for by the U.S. government.

UnitedHealthcare will reimburse CDC COVID-19 vaccination program providers for the administration of FDA-authorized and U.S. government provided COVID-19 vaccines. Reimbursement will be made in accordance with applicable state laws and federal provisions, including the CARES Act and FDA guidance, as outlined below. 

Updates and additional information will be posted on this site as quickly as possible when new information is available.

  • Medicare Advantage health plans: Charges for COVID-19 vaccine administration for all Medicare beneficiaries should be billed to the Center for Medicare & Medicaid Services (CMS) Medicare Administrative Contractor (MAC). The MAC will reimburse claims for Medicare beneficiaries with no cost share (copayment, coinsurance or deductible) for the remainder of 2020 and through 2021. For more information, visit the CMS COVID-19 Insurers Toolkit.
    • Any COVID-19 vaccine-related claims for Medicare beneficiaries that are submitted to UnitedHealthcare will be denied, and health care professionals will be directed to submit the claims to the MAC.
  • Employer and Individual health plans, including Student Resources, short term limited liability (STLD) and Exchange plans: UnitedHealthcare and self-funded customers covers the administration of COVID-19 FDA-authorized vaccines with no cost share for in- and out-of-network providers, during the national public health emergency period. Administration fees for in-network providers will be based on contracted rates. Administration fees for out-of-network providers will be based on CMS published rates.
  • Medicaid: Medicaid state-specific rules and other state regulations may apply. For Medicaid and other state-specific regulations, please refer to your state-specific website or your state’s UnitedHealthcare Community Plan website, if applicable. UnitedHealthcare will pay administration fees at CMS published rates unless otherwise specified.

In-Office Visits

  • For Employer and Individual health plans, UnitedHealthcare will reimburse for the vaccine administration at no cost share (copayment, coinsurance or deductible) for the member. Charges for the office visit and other services rendered during the visit will be adjudicated according to the member’s benefit plan.
  • For Medicare Advantage plans, if a member has a scheduled office visit with a health care professional and the COVID-19 vaccine is administered during that visit, the claim will need to be billed in two parts:
    • The MAC should be billed for the vaccine administration.
    • UnitedHealthcare should be billed for the office visit. 

Standard benefits and claims processing guidelines will apply.

CDC COVID-19 vaccination program providers may bill the UnitedHealthcare medical benefit through our standard claims process. Pharmacists should submit to their claims pharmacy platform. Reimbursement for vaccine administration services will be based on the provider’s contractual rate. State Medicaid may provide different guidance.

If an out-of-network provider bills above the CMS published rates for the administration of the vaccine, the member will not be held liable for payment of the administration service. Per federal provisions, a health care provider may not balance bill or impose cost share on a member for the cost of a vaccine or the administration when the U.S. government provides the vaccine. This applies for both in- and out-of-network providers. UnitedHealthcare’s standard payment integrity processes apply.

Claim Payments

UnitedHealthcare will begin paying COVID-19 vaccine administration claims once CMS rates are published. 

Members can review more information about the vaccine at the COVID-19 Vaccine Member Center.

The COVID-19 vaccine serum will initially be paid by the U.S. government.

Eligible members receiving the vaccine will not have any out-of-pocket costs (copayment, coinsurance or deductible), whether for the vaccine or the vaccine administration, when the U.S. government provides the vaccine. Health care professionals should not bill members for these claims.

For Individual and Group Market* health plans, UnitedHealthcare and self-funded customers will be required to cover the administration of COVID-19 vaccines with no cost share (copayment, coinsurance or deductible) for in- and out-of-network providers, during the national public health emergency period. Administration fees for in-network providers will be based on contracted rates. Administration fees for out-of-network providers will be based on CMS published rates.

*Does not apply to short-term duration health plans

There may be a limited supply of FDA-authorized COVID-19 vaccines available. The Centers for Disease Control and Prevention (CDC) and state health agencies will manage distribution and provide prioritization on which groups of people should get the vaccine first.

Vaccination Phase 1a is occurring now through January 2021 and Phase 1b and Phase 1c is expected in early 2021. The FDA is reporting that it is also likely that there will be a period of time where COVID-19 vaccines will not be recommended for children or women who are pregnant. However, clinical trials continue to expand participants. 

UnitedHealthcare aligns with America Medical Association (AMA) CPT® coding for medical claims. Health care professionals should use published AMA CPT codes when submitting COVID-19 vaccine administration claims to UnitedHealthcare under the member’s medical benefit.

Currently Approved AMA CPT Codes:

Manufacturer

Vaccine Dose CPT

National Drug Code

1st Administration CPT

2nd Administration CPT

Pfizer

91300

59267-1000-1

0001A

0002A

Moderna

91301

80777-273-10

0011A

0012A


Additional codes will be added as they become available.

Codes will be added to all applicable provider fee schedules as part of the standard quarterly code update and any negotiated discounts and premiums will apply to these codes. Codes will be added using the CMS published effective date for the codes and payment allowance as the primary fees source.

Modifiers

Modifiers are not required when submitting COVID-19 vaccine administration claims through the member’s medical benefit.

CPT® is a registered trademark of the American Medical Association.

Pharmacy Claim Submission and Administrative Costs

Pharmacies will be allowed to bill UnitedHealthcare directly for the costs associated with the administration of COVID-19 vaccines. Pharmacists administering the COVID-19 vaccine serum provided by the federal government should submit claims through their pharmacy claims platform. Claims for Medicare Advantage members should be billed to the applicable CMS Medicare Administrative Contractor (MAC)

National Council for Prescription Drug Programs (NCPDP) has designated two submission clarification codes (SCC) for pharmacy billing as the differentiating value for the dose currently being administered. OptumRx® is updating its claims system to allow different reimbursement rates based on the submitted SCC and professional service code value from the pharmacy:

SCC/PSC Value

Description

SCC 2

Indicates initial dose

SCC 6

Indicates that the previous medication was a starter dose and additional medication is needed to continue treatment

“MA” (Medication Administered)

Indicates that pharmacies can submit claims with a DUR PPS code = MA to trigger an administration fee


Additional information on billing pharmacy claims can be found in the NCPDP Emergency Preparedness Guidance –COVID-19 Vaccines guide.

We’re listening.

We’re committed to keeping you up to date on COVID-19 – we’re monitoring your inquiries and working hard to answer your questions. Let us know how we’re doing.

We’ll be making daily updates to this site. Be sure to check back often for the latest information. 


Disclaimer:

The benefits and processes described on this website apply pursuant to federal requirements and UnitedHealthcare national policy during the national emergency.  Additional benefits or limitations may apply in some states and under some plans during this time.

We will adjudicate benefits in accordance with the member’s health plan.

Medicaid Providers: UnitedHealthcare will reimburse out-of-network providers for COVID-19 testing-related visits and COVID-19 related treatment or services according to the rates outlined in the Medicaid Fee Schedule.