Texas Medicaid is making important updates to how it handles claims for respiratory syncytial virus (RSV) monoclonal antibody procedure code 90382. Effective for dates of service on or after July 01, 2025, procedure code 90382 will be processed as informational only. The administration fee tied to this code may still be reimbursed when submitted alongside RSV monoclonal antibody administration procedure codes 96380 and 96381.

RSV monoclonal antibodies, including nirsevimab (procedure codes 90380 and 90381) and clesrovimab (procedure code 90382), are available through the Texas Vaccines for Children (TVFC) program. Texas Medicaid will not reimburse claims for these vaccines for clients from birth through 18 years of age when the vaccines are available through TVFC and administered at a TVFC-eligible site. Those claims will instead be processed in the Medicaid Management Information System (MMIS) as informational details only.

Providers should also note that the Advisory Committee on Immunization Practices (ACIP) reviews RSV vaccine products annually and regularly updates its recommendations. Providers are encouraged to check the Centers for Disease Control and Prevention (CDC) website at https://www.cdc.gov/ for the most current guidance.

Claims Reprocessing

The Texas Medicaid & Healthcare Partnership (TMHP) will reprocess affected claims with dates of service from July 01, 2025, through August 01, 2026. Providers may receive additional reimbursement as a result, which will appear on future Remittance and Status (R&S) Reports.

Texas Medicaid Provider Procedures Manual (TMPPM) Updates

On August 01, 2026, TMHP will update the Texas Medicaid Provider Procedures Manual (TMPPM) to better distinguish between RSV vaccine procedure codes and RSV monoclonal antibody procedure codes. The following changes will be made:

In the Children's Services Handbook, section 4.5.5, "Respiratory Syncytial Virus (RSV)":

• RSV monoclonal antibodies (nirsevimab, procedure codes 90380 and 90381) may be administered to clients from birth through 19 months of age and are limited to two per lifetime.
• RSV monoclonal antibodies (clesrovimab, procedure code 90382) may be administered to clients from birth through 7 months of age and are limited to one per lifetime.
• Procedure codes 96380 and 96381 must be submitted alongside one of the monoclonal antibody procedure codes (90380, 90381, or 90382) to receive reimbursement for administration.

In the Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook, section 9.2.39, "Respiratory Syncytial Virus (RSV)":

• RSV vaccine (procedure codes 90679 and 90683) may be reimbursed for clients who are 50 years of age or older.
• RSV monoclonal antibodies (clesrovimab, procedure code 90382) may be administered to clients from birth through 7 months of age and are limited to two per lifetime.
• RSV monoclonal antibodies (nirsevimab, procedure codes 90380 and 90381) may be administered to clients from birth through 19 months of age and are limited to one per lifetime.

For questions, providers can call the TMHP Contact Center at 800-925-9126.

Note: Texas Medicaid managed care organizations (MCOs) must provide all medically necessary, Medicaid-covered services to enrolled members. Administrative procedures including prior authorization, precertification, referrals, and claims filing may differ from traditional Medicaid fee-for-service and from one MCO to another. Providers should contact the member's specific MCO for details.