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Provider Notice Issued 11/18/2021

Date:   November 18, 2021           

To:       Enrolled Physicians, Advanced Practice Nurses, Physician Assistants, Local Health Departments, Federally Qualified Health Centers, Rural Health Clinics, Encounter Rate Clinics, and Hospitals

Re:      COVID-19: Children Age 5-11 Vaccination Coverage; Vaccine Counseling Coverage; and Vaccine Additional Dose and Booster Dose Clarification

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This notice confirms COVID-19 vaccine coverage for children age 5 through 11 years, advises providers of coverage for COVID-19 vaccination counseling, and clarifies terminology regarding additional and booster COVID-19 vaccine doses. These policies apply to claims for participants covered under both traditional Medicaid fee-for-service and the HealthChoice Illinois Medicaid managed care plans.

Vaccination for Children Age 5 through 11 Years
Effective with dates of service beginning October 29, 2021, the following COVID-19 vaccination and administration codes have been added to the COVID-19 fee schedule:
 

  • 91307 - Pfizer-Biontech COVID-19 Vaccine (Age 5 through 11 years) 
  • 0071A - Pfizer-Biontech COVID-19 Vaccine Administration 1st Dose
  • 0072A - Pfizer-Biontech COVID-19 Vaccine Administration 2nd dose

 
COVID-19 Vaccination Counseling Service
Effective with dates of service beginning October 29, 2021, the Department will reimburse the following preventive medicine code that may be used to counsel customers regarding the benefits of receiving the COVID-19 vaccine: 
 

  • 99402 – Preventive medicine counseling and/or risk factor intervention/s provided to an individual (separate procedure); approximately 30 minutes
 
This code is limited to billing face-to-face visits for children ages 5 through 17. Parents or guardians of Medicaid-eligible children ages 5 through 17 may be counseled on the benefit of receiving the COVID-19 vaccination, even if the parent or guardian is not enrolled for Medicaid coverage. If the child receives the vaccine, the provider may bill both the appropriate visit code and the 99402 counseling code under the child's Recipient Identification Number. The timed 99402 counseling code would include the 15-minute post-vaccination observation period. The current rate for 99402 is $30.00.

If a parent or guardian ultimately declines the vaccine for the child, the provider should only bill the appropriate level of Evaluation and Management procedure code. Separate billing for counseling code 99402 is not available to federally qualified health centers, rural health clinics, and other entities billing an encounter rate.

Clarification of Additional and Booster Doses for Persons Age 18+
The additional dose of the Pfizer or Moderna COVID-19 vaccine for ages 18 and up is available for immunocompromised individuals who may not develop the same immune response level after vaccination as others. A customer may receive the additional dose at least 28 days after the customer's second vaccine dose.

A booster dose of the Pfizer, Moderna, and Janssen (Johnson & Johnson) COVID-19 vaccine is also available. A booster shot is recommended for certain individuals, as protection from the vaccine wanes over time.

A customer may receive a booster dose at least six months after the customer's second dose of the Pfizer and Moderna vaccines. A customer may receive a booster dose at least two months after the customer's initial Johnson and Johnson vaccine dose.

Specific recommendations regarding the populations endorsed for the additional and booster vaccinations are contained in Illinois Department of Public Health's Additional Dose and Booster Shot FAQ. Vaccine administration for the uninsured should continue to be billed through the federal HRSA COVID-19 Claims Reimbursement Portal.

The Department's COVID-19 Fee Schedule has been updated. Questions regarding this notice may be directed to a billing consultant in the Bureau of Professional and Ancillary Services at 877-782-5565, or the applicable managed care plan.

 
Kelly Cunningham, Administrator
Division of Medical Programs 



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JB Pritzker, Governor • Theresa Eagleson, Director