The California Medical Association (CMA) has received reports that Anthem Blue Cross is reimbursing the newly approved COVID-19 vaccine for the 5–11-year-old pediatric population at unreasonably low rates—less than 20% of the Centers for Medicare and Medicaid Services (CMS) reimbursement rate of $40/shot. Anthem has advised that while the new codes, CPT 0071A and 0072A, have been loaded into their systems, and physicians can submit claims using the new codes, there is still an additional step for the payor to update the pricing. The expected timeline for the updated pricing is still unclear.

Once Anthem has updated the pricing for the new codes, the payor advised it will conduct a sweep of all impacted claims and reprocess at the increased reimbursement rate.  

Unfortunately, this is not an isolated issue. Since the COVID-19 vaccines were approved in early 2020, some payors have been slow to update their systems to process vaccine administration claims correctly, resulting in claim denials and leaving physicians with no reimbursement for the services provided to newly eligible patients. While the problems are eventually identified and corrected, the lack of preparedness creates administrative and financial barriers for the physician community to administer COVID-19 vaccines. Addressing these barriers is critical to getting more individuals vaccinated.

CMA sent letters to the California Department of Managed Health Care (DMHC) and the California Department of Insurance (CDI) asking the agencies to encourage payors to proactively prepare their claims processing systems to correctly process COVID-19 vaccine administration claims from day one for newly eligible populations, particularly for the anticipated approval of the 5–11-year-old pediatric vaccine. DMHC and CDI both subsequently sent out notices instructing payors to update their systems without delay so physicians are not faced with unnecessary payment issues as California looks to vaccinate 3.5 million newly eligible kids aged 5-11 over the next couple of months.