Attention: COVID-19 Vaccine Administration Billing Guidance for Managed Long-Term Care Members without Medicare Coverage

  • Guidance is also available in Portable Document Format (PDF)

For members without Medicare coverage who are enrolled in a Medicaid Managed Long Term Care (MLTC) plan and use Medicaid Fee-for-Service (FFS) for pharmacy benefits, pharmacies will receive the following rejection response for COVID-19 vaccine administration claims when billed via the National Council for Prescription Drug Programs (NCPDP) pharmacy claim format.

  • Patient Is Not Covered, NCPDP reject code "AF"- Patient Enrolled Under Managed Care, for those MLTC members.

Such claims for COVID-19 vaccine administration may be submitted to FFS via ePACES as a professional real-time claim, providing the pharmacy is enrolled in Medicaid FFS with a category of service (COS) 0442. The Pharmacy must also submit a Place of Service code of "99" on the New York State 150003 form, field 24B.  For electronic 837P- Ref Loop 2300, CLM05-1- "99".

For information on how to enroll in COS 0442, go to: https://www.emedny.org/info/ProviderEnrollment/index.aspx

The following is a link to the reference guide for submitting a Professional real-time claim: https://www.emedny.org/selfhelp/ePACES/PDFS/5010_ePACES_Professional_Real_Time_Claim_Reference_Guide.pdf

Please see the New York State Medicaid Coverage Policy and Billing Guidance for the Administration of COVID-19 Vaccines Authorized for Emergency Use article for our full policy guidelines.

Medicaid FFS claim questions should be directed to the eMedNY Call Center at (800) 343-9000.

Medicaid FFS Pharmacy Policy questions should be directed to (518) 486-3209 or email ppno@health.ny.gov.