COVID-19 vaccine billing and reimbursement
COVID-19 vaccines are available to our members with no out-of-pocket costs*. Providers shouldn't collect any member cost share, such as copays, for any doses of COVID-19 vaccines or the administration of the vaccine.
The vaccine is currently being distributed at no cost to providers. You may bill for the administration of all doses of the vaccine using the following guidelines, which vary depending on your patient’s plan type.
For Medicare members
Currently, Medicare is paying for the COVID-19 vaccine and its administration through its original fee-for-service program. Submit claims for administering the COVID-19 vaccine to Medicare members to the CMS Medicare Administrative Contractor (MAC).
If you submit a claim to Priority Health for a Medicare member’s COVID-19 vaccine administration, we'll deny the claim and ask you to bill CMS directly.
For Medicaid members
Following state guidelines, you should bill the vaccine service with a billed amount of $0 plus the administrative service on the claim. We'll reimburse for the administrative fee at 100% of Medicaid rates.
We'll reimburse FQHCs, RHCs, THCs and Tribal FQHCs for COVID-19 vaccine administration when a Medicaid member doesn't receive another eligible qualifying clinic visit on the same date of service.
Submit claims for the administration of the vaccine to Priority Health using the codes listed in our Medicaid fee schedule (login required).
For commercial group and individual members
We'll add the COVID-19 vaccine to our Preventive Care Guidelines, which means most members will have $0 cost share. Some grandfathered plans—a plan that has not changed since 2010— or commercial retiree plans that aren't subject to the Affordable Care Act may have member costs.
Submit claims for the administration of the vaccine to Priority Health using the codes listed in our Commercial fee schedules (login required).
*Some grandfathered commercial plans, which are plans that haven't changed since 2010, or commercial retiree plans that are not subject to the Affordable Care Act may have member costs.