What insurance policy changes affect CPT 91323?

There are 11 tracked policy changes affecting CPT 91323, including updates from Blue Cross Blue Shield of Rhode Island, Connecticut Medicaid (HUSKY Health), Texas Medicaid. Each change may modify coverage criteria, reimbursement rates, or prior-authorization requirements.

Which payers have updated policy for CPT 91323?

Payers that have issued tracked updates for CPT 91323 include: Blue Cross Blue Shield of Rhode Island, Connecticut Medicaid (HUSKY Health), Texas Medicaid, Medicare/CMS, Pennsylvania Medicaid (DHS), Indiana Medicaid (IHCP), Kansas Medicaid (KanCare).

How do I get notified when CPT 91323 policy changes?

Create a free account at PolicyChanges.app and save a search filtered to CPT 91323. You will receive a daily digest email whenever a new policy change references this code.

Why do payers change policies for CPT 91323?

Payers revise policies for individual billing codes to align with updated clinical guidelines, CMS rule changes, fraud and abuse prevention measures, or network cost-management goals. Changes can affect medical necessity criteria, place-of-service restrictions, bundling rules, or whether a code requires prior authorization.

91323 Insurance Policy Changes

CPT 91323 is referenced in 11 tracked payer policy changes from Blue Cross Blue Shield of Rhode Island, Connecticut Medicaid (HUSKY Health), and 5 other payers. For billers and coders, staying current on payer-specific coverage criteria, reimbursement rules, and prior-authorization requirements for CPT 91323 is critical to clean claim submission. Each entry below links to the full policy analysis with effective dates and action steps.

High impact
Payment Policy Updates
Blue Cross Blue Shield of Rhode Island·Effective Jul 1, 2025
Multiple billing code updates effective July 1, 2025: 5 new immunization codes added, 4 codes deleted, 13 codes marked as non-reimbursable, new modifier requirements for off-campus institutional claims, and modifier 27 added for multiple outpatient E/M encounters.
Medium impact
2026.13 - Addition of COVID Vaccine Code to Select Clinic Fee Schedules
Connecticut Medicaid (HUSKY Health)·Effective Apr 1, 2026
Connecticut Medicaid (HUSKY Health) has added CPT code 91323 for the Moderna COVID vaccine (10 mcg/0.2ml IM) to the fee schedule for dialysis and medical clinics, effective April 1, 2026, with a reimbursement rate of $201.91. This vaccine is approved for high-risk individuals and those 65+ years old, with coverage extending to HUSKY Health members ages 19 and older.
Medium impact
2026.17 - April 2026 Quarterly HIPAA Compliant Update - Physician Office and Outpatient Fee Schedule; 2) Adding New Moderna COVID-19 Vaccine
Connecticut Medicaid (HUSKY Health)·Effective Apr 1, 2026
Connecticut Medicaid (HUSKY Health) has added new CPT code 91323 for Moderna COVID-19 vaccine with reimbursement rate of $201.91, effective April 1, 2026. The policy also incorporates April 2026 HCPCS updates to maintain HIPAA compliance for physician office and outpatient services.
Medium impact
Updated Texas Health Steps QRG Available January 30, 2026
Texas Medicaid·Effective Jan 30, 2026
Texas Health Steps Quick Reference Guide will be updated on January 30, 2026 to include COVID-19 vaccine procedure code 91323 in the Immunizations Administered table. This affects providers billing Texas Medicaid for pediatric COVID-19 vaccinations.
Medium impact
COVID-19 Vaccine Procedure Code 91323 a Benefit for Texas Medicaid and HTW Effective January 1, 2026
Texas Medicaid·Effective Jan 1, 2026
Effective January 1, 2026, Texas Medicaid and Healthy Texas Women (HTW) will cover COVID-19 vaccine procedure code 91323 and administration code 90480 for clients 12 years and older. TMHP will automatically reprocess affected claims for additional reimbursement.
Medium impact
2025-12-11 - CMS Finalizes New DMEPOS Accreditation Provisions to Enhance Program Integrity
Medicare/CMS·Effective Jan 1, 2026
CMS has finalized new DMEPOS accreditation provisions to enhance program integrity, with multiple payment rate updates and billing changes effective January 1, 2026. Key changes include new institutional provider enrollment fees of $750, updated payment rates for various services, and new billing requirements for critical access hospitals.
Medium impact
mab2025111301
Pennsylvania Medicaid (DHS)·Effective Nov 13, 2025
Pennsylvania Medical Assistance (Medicaid) is adding new procedure codes with various effective dates through January 2026, removing some codes, and implementing prior authorization requirements for durable medical equipment codes starting December 1, 2025. The policy also updates laboratory testing provider eligibility and adjusts post-operative days for certain surgical procedures.
Medium impact
BT202690: IHCP adds coverage for COVID-19 vaccine CPT code 91323
Indiana Medicaid (IHCP)·Effective Oct 6, 2025
IHCP now covers Moderna's mNexspike COVID-19 vaccine (CPT code 91323) for members age 19 and older, effective retroactively from October 6, 2025. The vaccine requires no prior authorization or NDC codes and reimburses at $185.98 maximum fee.
Medium impact
KMAP BULLETIN: Coverage of mNEXSPIKE
Kansas Medicaid (KanCare)·Effective Sep 1, 2025
Kansas Medicaid will now cover mNEXSPIKE (Code 91323) COVID-19 vaccination for members aged 65+ or aged 12-64 with high-risk conditions, effective retroactively to September 1, 2025. Billing varies by age: VFC applies for ages 18 and younger (administration only), while ages 19+ receive reimbursement for both vaccine cost and administration.
Medium impact
CPT code changes
Blue Cross Blue Shield of Rhode Island·Effective Jul 1, 2025
Blue Cross Blue Shield of Rhode Island has completed their review of July 2025 CPT code changes and will implement updates to their claims processing system effective July 1, 2025. The update includes new codes with various coverage designations including covered/reimbursed codes, not covered services, and codes requiring medical review.
Medium impact
BT202599: Coverage and billing information for the July 2025 quarterly HCPCS update
Indiana Medicaid (IHCP)·Effective Jul 1, 2025
Indiana Health Coverage Programs (IHCP) has updated coverage for the July 2025 quarterly HCPCS codes, with multiple new procedure codes being designated as noncovered and two codes (0240U and 0241U) being discontinued. All changes are effective for dates of service on or after July 1, 2025.

All billing codes J3590 99212 99213 99202 99211 99214

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Payment Policy Updates

2026.13 - Addition of COVID Vaccine Code to Select Clinic Fee Schedules

2026.17 - April 2026 Quarterly HIPAA Compliant Update - Physician Office and Outpatient Fee Schedule; 2) Adding New Moderna COVID-19 Vaccine

Updated Texas Health Steps QRG Available January 30, 2026

COVID-19 Vaccine Procedure Code 91323 a Benefit for Texas Medicaid and HTW Effective January 1, 2026

2025-12-11 - CMS Finalizes New DMEPOS Accreditation Provisions to Enhance Program Integrity

mab2025111301

BT202690: IHCP adds coverage for COVID-19 vaccine CPT code 91323

KMAP BULLETIN: Coverage of mNEXSPIKE

CPT code changes

BT202599: Coverage and billing information for the July 2025 quarterly HCPCS update