Date: November 1, 2021
Attention: All Providers
Effective Date: September 9, 2021Providers should monitor the Texas Children’s Health Plan (TCHP) Provider Portal regularly for alerts and updates associated to the COVID-19 event. TCHP reserves the right to update and/or change this information without prior notice due to the evolving nature of the COVID-19 event.
Call to action: Texas Children’s Health Plan would like to inform network providers that Texas Medicaid has revoked the Emergency Use Authorization (EUA) of bamlanivimab effective April 30, 2021, when administered alone for treatment of mild-to-moderate COVID-19. The FDA determined that the benefits of bamlanivimab no longer outweighed the risks. Bamlanivimab/etesevimab is still authorized.
Update November 1, 2021: This update is in response to the amended COVID-19 Public Readiness and Emergency Preparedness (PREP) Act declaration to allow pharmacists to order and administer selected COVID-19 therapeutics, including subcutaneous monoclonal antibodies (mAbs).
Effective for dates of service on or after September 9, 2021, pharmacists and pharmacies may now be reimbursed for procedure codes M0240, M0241, M0243, and M0244 rendered in the office, home, nursing home (skilled nursing facility/extended care facility) and intermediate care facility.
Claims with the procedure codes and place of service listed in the previous paragraph with dates of service on or after September 9, 2021 that are submitted by providers to TCHP will be automatically reprocessed. This is per the PREP Act declaration, by MCOs for appropriate payment to eligible providers no later than December 27, 2021, and providers may receive an additional payment.
Providers do not need to submit appeals unless they are denied for other reasons after the claims reprocessing is complete.
Monoclonal Antibody Therapy Administration Code M0243: effective for dates of service on or after July 30, 2021, diagnosis code Z20822, indicating possible exposure to COVID-19, will be added as a payable diagnosis for procedure code M0243 for monoclonal antibody therapy administration. Claims submitted with dates of service on or after July 30, 2021 will be automatically reprocessed by TCHP for appropriate payment to providers no later than October 24, 2021, and providers may receive an additional payment.
Providers do not need to submit appeals unless they are denied for other reasons after the claims reprocessing is complete.
Monoclonal Antibody Therapy procedure codes M0247 and Q0247: for dates of service on or after May 26, 2021, the reimbursement rates for COVID-19 Monoclonal Antibody Therapy procedure codes M0247 and Q0247 will be updated for Texas Medicaid and the Children with Special Health Care Needs (CSHCN) Services Program.
Monoclonal antibodies are used to treat COVID-19 and should be administered within 10 days of symptom onset. Qualifications to receive these medications include the following:
- Mild to moderate coronavirus disease (COVID-19) with a diagnosis of U07.1
- Patients twelve years old and older
- Patients with a weight of at least 40 kg or 88 pounds
- Patients that are at a high risk of progressing to severe COVID-19 or requiring hospitalization
These medications are not recommended for patients that have been hospitalized due to COVID-19 or require oxygen therapy.
How this impacts providers: The following codes are set up as payable. Bamlanivimab has been removed.
| Drug Name | Procedure Code | Administration Code | Date of Service Allowable (On/After) | Age / Weight / Diagnosis Restrictions |
| Casirivmab / Imdevimab | Q0243 Q0244 | M0243 | November 21, 2020
June 3, 2021 for Q0244
July 30, 2021 for M0243 | Diagnosis: U07.1 – Mild to Moderate COVID-19
Diagnosis: U07.1 – Mild to Moderate COVID-19 |
| Bamlanivimab / Etesevimab | Q0245 | M0245 | February 9, 2021 |
| Sotrovimab | Q0247 | M0247 | May 26, 2021 | Age > 12 years
Weight > 40 kg (88 lbs)
Diagnosis: U07.1 – Mild to Moderate COVID-19 |
Procedure codes M0243, M0245, and M0247 are a benefit for the following providers and places of service:
| Place of Services | Provider Type |
| Office | Physician assistant, nurse practitioner, clinical nurse specialist, physician (D.O), physician (M.D.), physician group (D.O.s only), clinic/group practice |
| Outpatient hospital | Hospital (long-term, limited, or specialized care), hospital (private full care), hospital (private, outpatient service, emergency care only) |
| Nursing home – skilled nursing facility/intermediate care facility (SNF/ICF) | Physician (D.O), physician (M.D.), physician group (D.O.s only), clinic/group practice |
| Nursing home – extended care facility (ECF) | Physician (D.O), physician (M.D.), physician group (D.O.s only), clinic/group practice |
Reference
Coronavirus (COVID-19) Update: FDA Revokes Emergency Use Authorization for Monoclonal Antibody Bamlanivimab
Next steps for providers: Providers should share this communication with their staff.
If you have any questions, please email Provider Network Management at: providerrelations@texaschildrens.org.For access to all provider alerts,log into:
www.thecheckup.org or
www.texaschildrenshealthplan.org/for-providers.
