Oregon Medicaid and COVID-19 Page 1 of 6 Last updated 9/23/2022
Vaccine Administration
Oregon Medicaid Coverage of COVID-19 Vaccine
Administration
The Oregon Health Plan (OHP) covers the administration of COVID-19 vaccine supplied to providers
through allocations from the federal government. This applies to vaccine administrations that:
Are delivered to Citizenship Waived Medical (CWM) members and OHP members;
Are ordered and administered by qualified practitioners, pharmacies, or staff; and
Meet FDA’s Emergency Use Authorization criteria for the vaccine.
This fact sheet explains how providers can enroll to become COVID-19 immunization providers and
bill the Oregon Health Authority (OHA) for fee-for-service (FFS) COVID-19 vaccine administration.
If you have questions about dental care organization (DCO) or coordinated care
organization (CCO) coverage, please contact the DCO or CCO.
To learn about Oregon’s vaccine distribution strategy and information for COVID-19
immunization providers, visit OHA’s COVID-19 for Health Care Providers page.
Provider enrollment
Enrollment as an Oregon immunization provider
Providers must first be enrolled with OHA as a COVID-19 immunization provider. To do this:
First, complete required ALERT IIS user and inventory training as described on OHA’s
COVID-19 Training for Vaccine Providers page.
After that, register using OHA’s online registration system.
o Existing immunization providers will log in with their ALERT IIS Organization Code
or Vaccines for Children PIN.
o New providers will use the Alert IIS Organization Code issued by OHA following
completion of required Alert IIS required training, user agreement and confidentiality
forms.
To learn more, view OHA’s instructions and checklists for COVID-19 vaccine provider enrollment.
Medicaid provider enrollment
To receive payment from OHP, providers must be OHP-enrolled; however, providers that are not
currently enrolled with OHP should not delay administering vaccine to OHP or CWM members.
OHA has made enrollment as streamlined as possible and will extend provider enrollment
retroactively, if necessary, to cover prior dates of service.
Unless there is evidence of a provider exclusion or license discipline, OHP is enrolling all
providers administering COVID-19 vaccine to OHP members.
To learn more about enrolling as an OHP provider, visit the OHP Provider Enrollment page.
Children’s COVID-19 and flu immunizations at OHP-enrolled pharmacies
To increase the number of places OHP-eligible children and families can go to access flu and
COVID-19 immunizations, OHA will not require Vaccines for Children (VFC) program enrollment for:
HEALTH SYSTEMS DIVISION
Medicaid Programs
Oregon Medicaid and COVID-19 Page 2 of 6 Last updated 9/23/2022
Vaccine Administration
Any OHP provider administering children’s COVID-19 immunizations; or
Any OHP-enrolled pharmacies providing children’s flu immunizations, for the duration of the
COVID-19 Public Health Emergency.
Pharmacies will need to enroll in the VFC program to provide any other children’s immunizations.
“No Wrong Door” policy for providers serving FFS and CCO members
OHA has implemented a “No Wrong Door” policy to ensure access for both FFS and CCO members
who present themselves at any OHP-enrolled COVID-19 vaccine provider location to receive a
COVID-19 vaccination.
Providers contracted with the member’s CCO should bill the CCO.
Providers not contracted with the CCO should bill OHA. Be sure to also contact your local
CCO(s) to explore direct contracting options. Find contact information at bit.ly/cco-contacts.
Counseling
Counseling patients about COVID-19 vaccine, including advising them about the risks from getting
and not getting vaccinated, is covered by OHP.
Reimbursement for up to 20 minutes of counseling, when provided at the same visit as a
vaccine administration, is included under the vaccine administration codes.
Reimbursement is available for time spent counseling at a vaccine administration visit in
excess of 20 minutes. See billing details below.
Reimbursement for counseling that does not occur at a vaccination visit is available under
covered Evaluation and Management codes.
For additional/booster doses:
Instruct members to get second dose vaccines on the date specified by the manufacturer’s product
labeling for products that require a second dose.
For guidance about additional doses for the immunocompromised and booster doses, please refer to
OHA’s COVID-19 immunization protocol. This document contains current guidance for COVID-19
immunization providers, including the COVID-19 vaccine schedule, recommendations for use,
contraindications, warnings and precautions, and other considerations.
Billing
Only bill for the vaccine administration, not the serum.
Use diagnosis code Z23 (Encounter for immunization).
Dentists billing OHA for vaccine administration are subject to OAR 410-123-1262.
Professional claim format
Enrolled physical health, dental and pharmacy providers may bill OHA for FFS COVID-19 vaccine
administration using the professional claim format, as described below.
To bill for counseling provided during the administration visit that exceeds 20 minutes, add
modifier 22.
On all claims related to COVID-19, also add modifier CR (Catastrophe/Disaster).
Oregon Medicaid and COVID-19 Page 3 of 6 Last updated 9/23/2022
Vaccine Administration
Ages 6 months through 4 years
Code
Description
Effective
Rate
0081A
Pfizer-BioNTech – Infant/Toddler First Dose
6/19/2022
$40.00
0082A
Pfizer-BioNTech – Infant/Toddler Second
Dose
6/19/2022
$40.00
0083A
Pfizer-BioNTech – Infant/Toddler Third Dose
6/19/2022
$40.00
Ages 6 months through 5 years
Code
Description
Rate
0111A
Moderna – Infant/Toddler First Dose
$40.00
0112A
Moderna – Infant/Toddler Second Dose
$40.00
Ages 5 to 11 years
Code
Description
Rate
0071A
Pfizer-BioNTech Pediatric – First Dose
$40.00
0072A
Pfizer-BioNTech Pediatric – Second Dose
$40.00
0073A
Pfizer-BioNTech Pediatric – Third Dose
$40.00
0074A
Pfizer-BioNTech Pediatric – Booster Dose
$40.00
Ages 12 years and older
Code Description
Minimum
age Effective
Rates
Through
3/14/2021
On or after
3/15/2021
0001A
Pfizer-BioNTech – First Dose
16 years
12/13/2020
$16.94
$40.00
0001A
Pfizer-BioNTech – First Dose
12 years
5/13/2021
N/A
$40.00
0051A
Pfizer-BioNTech – First Dose
(preservative free, 30 mcg/0.3 mL
dosage, tris-sucrose formulation)
12 years
10/29/2021
N/A
$40.00
0002A
Pfizer-BioNTech – Second Dose
16 years
12/13/2020
$28.39
$40.00
0002A
Pfizer-BioNTech – Second Dose
12 years
5/13/2021
N/A
$40.00
0052A
Pfizer-BioNTech – Second Dose
(preservative free, 30 mcg/0.3 mL
dosage, tris-sucrose formulation)
12 years
10/29/2021
N/A
$40.00
0003A
Pfizer-BioNTech – Third Dose
12 years
8/12/2021
N/A
$40.00
0053A
Pfizer-BioNTech – Third Dose
(preservative free, 30 mcg/0.3 mL
dosage, tris-sucrose formulation)
12 years
10/29/2021
N/A
$40.00
0004A
Pfizer-BioNTech – Booster Dose
18 years
9/22/2021
N/A
$40.00
0004A
Pfizer-BioNTech – Booster Dose
16 years
12/09/2021
N/A
$40.00
0004A
Pfizer-BioNTech – Booster Dose
12 years
1/5/2022
N/A
$40.00
0054A
Pfizer-BioNTech – Booster Dose
(preservative free, 30 mcg/0.3 mL
dosage, tris-sucrose formulation)
12 years
10/29/2021
N/A
$40.00
0124A
Pfizer-BioNTech – Booster Dose
(preservative free, 30 mcg/0.3 mL
dosage, tri-sucrose bivalent formulation)
12 years
9/01/2022
N/A
$40.00
0011A
Moderna – First Dose
18 years
12/18/2020
$16.94
$40.00
0012A
Moderna – Second Dose
18 years
12/18/2020
$28.39
$40.00
0013A
Moderna – Third Dose
18 years
8/12/2021
N/A
$40.00
0064A
Moderna – Booster Dose
18 years
10/21/2021
N/A
$40.00
Oregon Medicaid and COVID-19 Page 4 of 6 Last updated 9/23/2022
Vaccine Administration
Code
Description
Minimum
age
Effective
Rates
Through
3/14/2021
On or after
3/15/2021
0094A
Moderna – Booster Dose
18 years
3/29/2022
N/A
$40.00
0134A
Moderna – Booster Dose
(preservative free, 50 mcg/0.5 mL
dosage, bivalent)
18 years
9/01/2022
N/A
$40.00
91303
Johnson & Johnson – Janssen Vaccine
18 years
2/28/2021
N/A
N/A
0031A
Johnson & Johnson – Janssen – Single
Dose
18 years
2/28/2021
$28.39
$40.00
0034A
Johnson & Johnson – Janssen –
Booster Dose
18 years
10/21/2021
N/A
$40.00
0041A
Novavax – First Dose
18 years
7/19/2022
N/A
$40
0041A
Novavax – First Dose
12 years
8/22/2022
N/A
$40
0042A
Novavax - Second Dose
18 years
7/19/2022
N/A
$40
0042A
Novavax - Second Dose
12 years
8/22/2022
N/A
$40
* OHP updated rates on 3/16/2021. OHP will work with you to adjust claims if you were paid the wrong rate on 3/15/2021.
Institutional claim format
For hospital inpatient FFS COVID-19 vaccine administration, split bill as an outpatient service as
follows:
Type of Bill: 131
Statement Covers Period (From and To Dates): Use the discharge date of the inpatient claim.
Condition Code: DR (Disaster-Related)
Revenue Code: 771
Pharmacy point of sale claims
To bill OHA, enter information as follows. OHA will pay the fee (“Incentive Amount”) listed below.
Separate reimbursement for counseling is not available through point of sale. To bill for more than 20
minutes of counseling or counseling that does not occur during the vaccine administration visit, use
the professional claim format.
NCPDP Field
Multi-Dose Vaccines
Single-Dose Vaccines
Rates through
3/14/2021
Rates on and after 3/15/2021*
Rates
through
3/14/2021
Rates on
and after
3/15/2021
1
st
Dose
2
nd
Dose
1
st
Dose
2
nd
Dose
3
rd
Dose
Professional
Service Code
440-E5
MA
MA
MA
MA
MA
MA
MA
Service
Clarification
Code
452-DK
2
6
2
6
7
<leave
blank>
<leave
blank>
Incentive
Amount
483-E3
$16.94
$28.39
$40.00
$40.00
$40.00
$28.39
$40.00
Basis of Cost
423-DN
15
15
15
15
15
15
15
Oregon Medicaid and COVID-19 Page 5 of 6 Last updated 9/23/2022
Vaccine Administration
NCPDP Field
Multi-Dose Vaccines
Single-Dose Vaccines
Rates through
3/14/2021
Rates on and after 3/15/2021*
Rates
through
3/14/2021
Rates on
and after
3/15/2021
1
st
Dose
2
nd
Dose
1
st
Dose
2
nd
Dose
3
rd
Dose
Ingredient Cost
409-D9
$0.00 or
$0.01
$0.00 or
$0.01
$0.00 or
$0.01
$0.00 or
$0.01
$0.00 or
$0.01
$0.00 or
$0.01
$0.00 or
$0.01
*OHP updated rates on 3/16/2021. OHP will work with you to adjust claims if you were paid the wrong rate on 3/15/2021.
Additional payment for in-home COVID-19 vaccine administrations
OHA can reimburse providers an additional $35.50 for administering COVID-19 vaccines to FFS
OHP or CWM members in their home or dwelling, for dates of service on or after June 8, 2021.This
fee:
Is in addition to the base vaccine administration rates listed above,
Applies only once per visit for members who are unable to leave to their home or otherwise
difficult to reach as described in the Centers for Medicare & Medicaid Services (CMS) fact
sheet about the fee, and
Does not apply to providers paid at an all-inclusive encounter rate for COVID-19 vaccine
administration, including Federally Qualified Health Centers, Rural Health Clinics, Indian
Health Services and Tribal 638 programs.
Code
Description
Place of Service Code
Effective
Date
Rate
M0201
COVID-19 vaccine administration
inside a patient's home; reported
only once per home per date of
service
04 (Homeless Shelter)
12 (Home)
13 (Assisted Living Facility
14 (Group Home)
16 (Temporary Housing)
06/08/2021 $35.50
Situations where the additional payment applies:
Providers may provide in-home vaccinations to patients who are unable to leave their home or
otherwise difficult to reach. For example, the individual:
Has a condition that makes them more susceptible to contracting a pandemic disease such as
COVID-19.
Is generally unable to leave the home, and if they do leave home it requires a considerable
and taxing effort.
Has a disability or faces clinical, socioeconomic, or geographical barriers to getting a COVID-
19 vaccine in settings other than their home.
Faces challenges that significantly reduce their ability to get vaccinated outside the home,
such as challenges with transportation, communication, or caregiving.
Locations where the additional payment applies:
To be eligible for the additional payment, the COVID-19 vaccine may be administered in these
locations:
A private residence
Temporary lodging (for example, a hotel or motel, campground, hostel, or homeless shelter)
An apartment in an apartment complex or a unit in an assisted living facility or group home
Oregon Medicaid and COVID-19 Page 6 of 6 Last updated 9/23/2022
Vaccine Administration
A patient's home is provider-based to a hospital during the COVID-19 public health
emergency (i.e., hospital at home)
You must document the patient’s clinical status or the barriers they face to getting the vaccine
outside the home.
Frequently asked questions
Are OHP or CWM members required to pay for their COVID-19 vaccinations?
No. OHP and CWM members should not be billed under any circumstance nor should they be
requested to make “voluntary” payments.
If a member has both Medicare and Medicaid coverage, who pays?
Bill Medicare as the primary payer.
Can members use Non-Emergency Medical Transportation (NEMT) services for vaccine
appointments?
Yes. OHP members can use NEMT to travel to the nearest local COVID-19 vaccination clinic,
including alternative sites (e.g., fairgrounds, drive-through locations).
Additionally, OHP members receiving Medicaid-funded personal care services from a homecare
worker (HCW) or personal support worker (PSW) may be transported to the nearest local COVID-19
vaccination clinic, including alternative sites, by their HCW/PSW. These members should contact
their local case management entity for more information and prior authorization.