Billing and Reimbursement

Last update: May 13, 2021, 10:42 a.m. CT

Please follow the instructions below for submitting COVID-19 vaccine administration claims, based on the member’s health plan.

Please follow the instructions below for submitting COVID-19 vaccine administration claims, based on the member’s health plan.

Health plan

Medical

Pharmacy

Medicare Advantage

Bill claims for COVID-19 vaccine administration to the applicable Center for Medicare & Medicaid Services (CMS) Medicare Administrative Contractor (MAC). For more information, visit the CMS COVID-19 Insurers Toolkit.

Note:

+   Incorrectly Submitted Claims: 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.

+   In-Office Visits: 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:

o The MAC should be billed for the vaccine administration.

o UnitedHealthcare should be billed for the office visit. 

Medicare ID lookup: When billing to the MAC, you will need to include the members Medicare Beneficiary Identifier (Medicare ID) number which is different than the member’s assigned UnitedHealthcare member ID number. Follow our step-by-step guide to learn how to look up a member’s Medicare ID number in the UnitedHealthcare Provider Portal. 

Bill claims for COVID-19 vaccine administration to the applicable Center for Medicare & Medicaid Services (CMS) Medicare Administrative Contractor (MAC). For more information, visit the CMS COVID-19 Insurers Toolkit.

Note: 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.

Medicare ID lookup: If a member is at the pharmacy and doesn’t have their Medicare ID number, the pharmacist may be able to get assistance by calling the OptumRx pharmacy help desk.

Employer and Individual health plans, including Student Resources, short-term limited liability (STLD) and Exchange plans

Health care professionals administering the COVID-19 vaccine serum provided by the federal government should submit medical claims through our standard claims process.

UnitedHealthcare will pay an administrative fee to the health care professional that covers the vaccine administration and the member’s observation with no cost share. 

In-Office Visits: If a member has a scheduled office visit with a health care professional and the COVID-19 vaccine is administered during that visit, charges for the office visit and other services rendered during the visit should be submitted through our standard claims process. Benefits will be adjudicated according to the member’s health plan.

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.

Medicaid

Participating health care professionals may bill the UnitedHealthcare medical benefit through our standard claims process.

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.

Standard benefits and claims processing guidelines will apply.

Reminder: You should not bill UnitedHealthcare members at the time of service for any costs associated with the COVID-19 vaccine. Claims for vaccine administration should be submitted as outlined, based on the member’s benefit plan. There is no cost to the member for the COVID-19 vaccine, and most plans are covering the administration of the COVID-19 vaccine at no cost share for the member.

UnitedHealthcare aligns with American 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.

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 and payment allowance as the primary fee’s source.

Modifiers are not required when submitting COVID-19 vaccine administration claims. 

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

Janssen

91303

59676-0580-05

0031A

NA

 

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. 

Reminder: You should not bill UnitedHealthcare members at the time of service for any costs associated with the COVID-19 vaccine. Claims for vaccine administration should be submitted as outlined, based on the member’s benefit plan. There is no cost to the member for the COVID-19 vaccine, and most plans are covering the administration of the COVID-19 vaccine at no cost share for the member.

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

Health plan

Reimbursement Information

Medicare Advantage

Administration fees for Medicare plans will be covered by Medicare Fee-for-Service (FFS) and be reimbursed according to CMS published rates for both in-network and out-of-network providers.

The Center for Medicare & Medicaid Services (CMS) Medicare Administrative Contractor (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.

Employer and Individual health plans, including Student Resources, short-term limited liability (STLD) and Exchange plans

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.

These reimbursement rates apply unless otherwise specified by state regulations.

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.

Medicaid

For members covered under UnitedHealthcare Medicaid (Community Plan) benefit plans, UnitedHealthcare will pay at state designated rates, unless specified otherwise. State-specific rules and other state regulations may apply. Some state agencies have not yet advised how they will cover this benefit or their reimbursement strategy. Please refer to your state-specific website or your state’s UnitedHealthcare Community Plan website for more details. 

Cost Share Information

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 cost share (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. Reminder: At the time of service, you should not ask UnitedHealthcare members for payment of any costs associated with the COVID-19 vaccine.

Vaccine-related services

If members receive additional services during their vaccination appointments, they may be responsible for copays, deductibles, coinsurance or out-of-network charges, according to their benefits plan.

Health care professionals should not charge members for standard observation (15–30 minutes after receiving the vaccination).

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.

UnitedHealthcare pays an administrative fee to the health care professional that covers the vaccine administration and the member’s observation following the vaccination with no cost share.

*Does not apply to short-term duration health plans

Roster billing is a way for health care professionals to submit multiple claims at once for mass immunization practices.

We’re working with Exela Technologies — an outside vendor company — to help facilitate the roster billing process. Before you submit claims, please ensure you meet the following criteria for roster billing:

  • Participating in a multi-TIN mass vaccination site upon registration
  • Providing services for members covered under a UnitedHealthcare Individual and Group Market fully insured health plan
  • Each individual TIN should have a separate roster for eligible members

If you qualify for roster billing, follow the steps outlined in the UnitedHealthcare roster billing quick reference guide to submit new claims. 

Tools to Use

These resources may be helpful as you manage the claim submission and reimbursement process for COVID-19 vaccine administration:

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.