Covered and Noncovered Services : Covered Services and Requirements

Immunizations

Providers are required to indicate the procedure code of the actual vaccine administered, not the administration code, on claims for all immunizations. Reimbursement for both the vaccine, when appropriate, and the administration are included in the reimbursement for the vaccine procedure code, so providers should not separately bill the administration code. Providers are required to indicate their usual and customary charge for the service with the procedure code.

The immunizations identified by CPT subsections "Immune Globulins" (procedure codes 90281-90399) and "Vaccines, Toxoids" (procedure codes 90476-90749) are covered.

Immune globulin procedure codes and the unlisted vaccine/toxoid procedure code are manually priced by ForwardHealth's pharmacy consultant. To be reimbursed for these codes, physicians are required to attach the following information to a paper claim:

• Name of drug
• NDC
• Dosage
• Quantity (for example, vials, milliliters, milligrams)

Medicaid reimbursement for immune globulins, vaccines, toxoid immunizations, and the unlisted vaccine/toxoid procedure codes includes reimbursement for the administration component of the immunization, contrary to CPT's description of the procedure codes. Procedure codes for administration are not separately reimbursable.

Vaccines for Children 18 Years of Age or Younger

Most vaccines provided to members 18 years of age or younger are available through the federal VFC Program at no cost to the provider. If a vaccine is available through the VFC Program, providers are required to use vaccines from VFC supply for members 18 years of age or younger. ForwardHealth reimburses only the administration fee for vaccines supplied by the VFC Program.

For vaccines that are not supplied by the VFC Program, providers may use a vaccine from a private stock. In these cases, ForwardHealth reimburses for the vaccine and the administration fee.

The Wisconsin Immunization Program has more information about the VFC Program. Providers may also call the VFC Program at 608-267-9959 or email VFC@dhs.wisconsin.gov.

Vaccines that are commonly combined, such as MMR or DTaP, are not separately reimbursable unless the medical necessity for separate administration of the vaccine is documented in the member's medical record.

If a patient encounter occurs in addition to the administration of the injection, physicians may receive reimbursement for the appropriate E&M procedure code that reflects the level of service provided at the time of the vaccination. If an immunization is the only service provided, the lowest level E&M office or other outpatient service procedure code may be reimbursed, in addition to the appropriate vaccine procedure code(s).

Vaccines for Members 19 Years of Age or Older

For vaccines from a provider's private stock that are administered to members 19 years of age or older, ForwardHealth reimburses for the vaccine and the administration fee.