Immunization Program

Patient Eligibility Chart

2007/2008 Summary of Reimbursement Questions from RI Insurers

Blue Cross

• Click here for summary chart for Blue Cross. This includes Blue Cross commercial and Medicare managed care products.
• Reimbursement dollar amount differs by product type.
• Providers must bill with a vaccine code (from 90476-90749 CPT series), even if it is state-supplied.
• Separate CPT codes for vaccine and for administration will be paid. (new policy effective 10/15/07)
• Employees of Citizens Bank (prefix code CZF) may have co-insurance/deductible for flu shot.
• Flu shots are covered for all beneficiaries in all settings, including public clinics.
• If flu vaccine is not state-supplied, when billing for vaccine, use 22 modifier. State supply must be used if patient is eligible.
• If a flu shot is given during an office visit, providers can submit claim for and office visit and administration of flu vaccine only when a separately identifiable E/M service is provided.
• If patient is only getting a flu shot from a private provider (no office visit) there is no office co-pay.
• If a patient goes to an urgent care for flu shot only, (no office visit) there is no office visit co-pay.
• Flu shots are considered a preventive service and do not apply towards deductibles, except as noted above.

Medicare Fee For Service (part B)

• Click here for summary chart for Medicare Fee for Service.
• If vaccine is state-supplied, DO NOT use vaccine CPT code for vaccine.  Only use GOOO8 - it is specific to flu vaccine administration.
• If vaccine is not state-supplied, use vaccine CPT code and bill for vaccine
• If a flu shot is given during an office visit, providers can submit a claim for an office visit and administration of flu vaccine with an identifiable E&M code.
• If patient is only getting a flu shot from a private provider (no office visit) there is no office co-pay.
• If a patient goes to an urgent care for flu shot only, (no office visit) there is no office visit co-pay.
• Flu shots are considered a preventive service and do not apply towards deductibles.

Neighborhood Health

• Click here for a summary chart for Neighborhood Health.
• Providers must bill $.50 for vaccine even if it is state-supplied.
• If a flu shot is given during an office visit, providers can submit a claim for an office visit and administration of flu vaccine—using a 25 modifier.
• Neighborhood does not cover flu shots given at public clinics.

UnitedHealthcare

• Click here for a summary chart for United. This includes United commercial and Medicare managed-care products.
• Reimbursement dollar amount is $8.50 for non-participating providers. Reimbursement dollar amount for participating providers varies by individual provider contract.
• Providers must bill $.50 for vaccine even if it is state-supplied.
• Claims submitted electronically will be paid sooner.
• If a patient receives a flu shot from a non-participating provider, the patient can submit a claim to United. Payment to the patient is contingent upon the patient’s benefit package.
• If a public clinic is roster billing, there is no co-pay for patient.
• Providers do not need to submit separate roster bills for state-supplied vaccine and non state-supplied vaccine.
• Roster billing is available to members of the Ocean State Adult Immunization Coalition and home health agencies that are not contracted to provide this service.
• All mass immunizers who are participating United providers must submit flu clinic schedule to United. Any changes or updates must also be submitted to United.
• If a mass immunizer has to reschedule a public clinic due to unforeseen circumstances (inclement weather, vaccine supply) information for the rescheduled clinic needs to be submitted to United as soon as possible. In addition, the rescheduled clinic does need to be approved again.
• Flu shots are a covered benefit if given by a private provider or at a public clinic. A public clinic is defined as a clinic that is posted on the Department of Health website and is open to anyone who wishes to attend. (This does not include public clinics offered at worksites.)
• If a flu shot is given during an office visit, providers can submit a claim for an office visit and administration of flu vaccine – using an E&M code with a 25 modifier.
• If a patient is only getting a flu shot from a private provider, office visit co-pays do not apply.
• If a patient goes to an urgent care facility for a flu shot only (no office visit) the office visit co-pay does apply.
• A provider will be reimbursed for administration of a flu shot given at an assisted living facility assuming the provider is contracted to provide this type of service and it is covered under the patient’s benefit package.
• Payment for administration of flu shot does apply to deductibles.

 
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