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Clarification for COVID-19 Vaccine and Monoclonal Antibody Treatment Reimbursement for Commercial and Medicare Advantage Lines of Business

Audience: Physicians, Behavioral Health and Substance Use Facilities, Infusion Centers, Skilled Nursing Facilities, Home Health Care Providers

In previous communications related to the COVID-19 vaccine and monoclonal antibody treatment, we shared that we would mirror the Medicare rates established by the Centers for Medicare & Medicaid Services (CMS) for Medicare Advantage and commercial products/lines of business.

We wish to clarify that we will use the geographically adjusted Medicare rates (i.e., the rates applicable to upstate NY) to reimburse COVID-19 vaccine administration and the infusion administration for monoclonal antibody treatment.  These rates are the same as what you receive for treating Medicare fee-for-service patients. Our claims system has been updated to reflect the geographically adjusted Medicare rates, including the March 15, 2021, CMS update for COVID-19 vaccine administration rates.

What this means for your practice or facility

COVID-19 vaccine administration: We will auto-adjust claims with dates of service on or after March 15, 2021, to reflect the CMS geographically adjusted vaccine administration rates (which are higher than the previous rates). There is no action required on your part to initiate an adjustment and no need to resubmit claims.

COVID-19 monoclonal antibody infusion administration: Any claims for monoclonal antibody infusion administration processed or adjusted on or after April 4, 2021, will be paid at the updated geographically adjusted rates. We will not adjust previously paid claims to recoup the difference between the higher national CMS rate paid and the geographically adjusted rates.

Please keep in mind that COVID-19 vaccines administered to Medicare Advantage members by Medicare Advantage contracted providers should be submitted to Original Medicare following the instructions included on the CMS website:

If you have any questions, please contact your Provider Relations representative.

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