NC Medicaid COVID-19 Vaccine Guidelines for 2026-2027

Already effective October 1, 2024: Billing team should verify that the practice has transitioned from CPT 99401 (COVID-19 vaccine counseling) to HCPCS codes G0310, G0312, and G0315 for stand-alone vaccine counseling when vaccines are not administered on the date of service, and confirm current applicability. Already effective January 1, 2025: Billing team should verify that pharmacy providers can submit COVID-19 vaccine claims at point-of-sale for NC Medicaid Direct beneficiaries ages 3 and older, and that the CG modifier is appended to ALL COVID-19 vaccine AND administration CPT codes on pharmacy claims. For the 2026-2027 season (current): Update billing software, superbills, and claim templates to reflect the new vaccine-specific CPT codes (91319, 91320, 91321, 91322, 91323, 91304) with their corresponding 11-digit NDCs listed in Table 1, ensuring correct NDC-CPT matching to avoid edit 00996 (Mismatched NDC) denials. Billing team must ensure that: (1) ICD-10 code Z23 is reported on all COVID-19 vaccine claims; (2) EP modifier is appended to vaccine administration codes for beneficiaries under age 21; (3) UD modifier is appended for 340B drugs with actual acquisition cost billing; (4) Both administration CPT codes (90471, 90472, or 90460) and vaccine CPT codes are included on claims for payment; and (5) pharmacy claims include the CG modifier. For NC Medicaid Managed Care, providers should refer to each plan's specific guidance (Alliance, AmeriHealth Caritas North Carolina, Carolina Complete Health, Healthy Blue of North Carolina, Trillium Health Resources, United Health Care of North Carolina, Vaya Partners) for COVID-19 vaccine claim submission. Verify whether VFC-eligible beneficiaries (ages 6 months–18 Medicaid-eligible children) are receiving vaccines through the state's free NCIP/VFC program, and bill only administration fees for those beneficiaries, not vaccine costs.