CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Immunizations and vaccinations — payment and claims guidelines

Payment and claims guidelines for immunizations and vaccinations for pediatric and adult members of Blue Cross & Blue Shield of Rhode Island, including Medicare Advantage and commercial products, and state-supplied vaccine rules for Rhode Island.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyImmunizations and vaccinations — payment and claims guidelines

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateOct 15, 2007

Next Review DateN/A

Key ActionWhen multiple vaccines are administered on the same date by the same provider, file add-on administration codes (90461, 90472 or 90474) and indicate the number of units.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

90460-90474Administration codes listed

ListedMedicare Part B vaccines

DOHState-supplied pediatric vaccines

Not coveredTravel counseling

Coverage rules and scope

Coverage by product and program

Coverage provisions vary by product and setting as summarized below.

ALL of the following

Medicare Advantage Plans
- Medicare Part B covers specific vaccines and administration when billed under Part B (examples: pneumococcal, influenza, COVID-19, hepatitis B for individuals at high or intermediate risk [requires ICD-10-CM Z23], and vaccines related to treatment of injury or exposure such as rabies and tetanus).see Part B listing
- All other vaccines not listed as Part B benefit are covered under the member's Medicare Part D drug benefit.
Commercial Products
- Commercial coverage: vaccinations/immunizations are covered when recommended by CDC and AAP and when FDA guidelines are met; benefits may vary by group/contract—refer to the applicable Benefit Booklet/Evidence of Coverage/Subscriber Agreement.
- BCBSRI will waive cost-share (co-pays and/or deductibles) for COVID-19 immunizations in and out of network for fully insured and certain municipal self-funded employer groups per RI guidance.
Rhode Island state-supplied vaccines
- The Rhode Island Department of Health (DOH) provides biologicals for pediatric immunizations for members residing in Rhode Island; BCBSRI does not reimburse providers for immunization biologicals supplied by DOH or other state/federal agencies and follows DOH guidance on which vaccines are state-supplied.
Program-specific notes
- For Medicare Advantage members there is no out-of-pocket expense for flu and pneumococcal vaccines and administration (considered Part B drugs); Shingles and RSV administration and supply and other Part D adult vaccines recommended by ACIP have no out-of-pocket expense per IRA guidance as noted.
- For Commercial members: flu administration and supply, COVID-19 vaccine and administration, RSV vaccine and administration, and shingles vaccine administration and supply are listed; pneumococcal vaccines are not submitted under the Vaccine Retail Program for Commercial products—members are responsible for payment and may request coverage from Blue Cross for other vaccines not noted.

Coverage criteria and billing rules (excerpt)

Lists of covered CPT/HCPCS vaccine and administration codes for Medicare Advantage and Commercial products, plus explicit non‑covered items and billing instructions.

ALL of the following

Covered administration codes include (partial listing): 90460, 90461, 90471, 90472, 90473, 90474, 90480, 96380, 96381 (see coding section for full list).

Medicare Advantage vaccine/HCPCS codes (selected highlights)

Selected Part B covered vaccine/HCPCS codes include: 90380, 90381 (RSV monoclonal antibody seasonal doses), 90611 (smallpox/monkeypox vaccine), multiple influenza and pneumococcal codes (see Medicare Advantage code list).

Commercial vaccine codes (selected highlights)

Selected Commercial covered vaccine codes include: 90380, 90381 (RSV monoclonal antibody), 90611 (smallpox/monkeypox), 90476–90477 (adenovirus oral vaccines), meningococcal and rabies codes, RSV vaccines 90678/90679 (effective 10/1/2023), and others listed in the Commercial section.

Member billing for non-covered services

Provider billing and member-charge stance for non‑covered services.

ALL of the following

Providers may not charge members for services determined to be not medically necessary or that are non-covered benefits unless the member has been informed and has agreed in writing in advance to continue at their own expense per the provider participation agreement.

Codes and reporting guidance

Covered administration and vaccine codes (partial list)mixedCovered

90460	Immunization administration through 18 years with counseling; first component
90461	Each additional vaccine/toxoid component through 18 years with counseling
90471	Immunization administration; one vaccine
90472	Each additional vaccine administration
90473	Intranasal/oral immunization administration; one vaccine
90474	Each additional intranasal/oral vaccine
90480	Immunization administration by intramuscular injection of SARS-CoV-2 single dose
96380	Administration of RSV monoclonal antibody, seasonal dose IM with counseling
96381	Administration of RSV monoclonal antibody, seasonal dose IM
90380	RSV monoclonal antibody, seasonal dose; 0.5 mL (Part B)

1–10 of 12

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Selected covered vaccine/HCPCS codes (Medicare Advantage highlights)CPTCovered

90380	Respiratory syncytial monoclonal antibody, seasonal dose; 0.5 mL, IM
90611	Smallpox and monkeypox vaccine, attenuated vaccinia virus, non-replicating, 0.5 mL, SC, adults
90671	Pneumococcal conjugate vaccine, 15-valent (PCV15), IM (Effective 7/1/2021)
91320	SARS-CoV-2 vaccine, mRNA LNP, 30 mcg/0.3 mL, IM

Selected covered vaccine codes (Commercial highlights)CPTCovered

90678	RSV vaccine, subunit; bivalent; IM (Effective 10/1/2023)
90679	RSV vaccine, recombinant; subunit; adjuvanted; IM (Effective 10/1/2023)
90750	Zoster recombinant; subunit; adjuvanted; IM (age 50+), 2-dose

Non-covered / contract exclusions (pending FDA approval)CPTNot Covered

90666	Influenza vaccine (IIV), pandemic formulation — pending FDA approval
90667	Influenza vaccine (IIV), pandemic formulation adjuvanted — pending FDA approval
90668	Influenza vaccine (IIV), pandemic formulation — pending FDA approval

Referenced vaccine codesCPT

90636

CPT/HCPCS code referenced in document (example influenza/pneumococcal-related coding mention)

Multiple vaccines same date

Applicable add-on codes90461, 90472, 90474

When to useFor claims with multiple vaccines administered on the same date of service by the same provider, file the administration add-on codes

Claim filing detailIndicate the number of units used for each add-on code on the claim

Administration add-on unit reporting

Unit reporting requirementIndicate number of units when billing add-on administration codes (90461, 90472, or 90474)

Provider conditionApplies when multiple vaccines are administered on the same date of service by the same provider

Associated primary codesUse add-on codes in conjunction with primary administration codes such as 90460 or 90471 as appropriate

Provider responsibilities and billing notes

Prior Authorization

Not applicable

Billing Rule

Administration coding and multiple-vaccine billing note

The following CPT administration codes are covered for Medicare Advantage and Commercial products. When multiple vaccines are administered on the same date of service by the same provider, file the appropriate administration add-on code(s) and indicate the number of units used.

Covered administration CPT codes: 90460, 90461, 90471, 90472, 90473, 90474, 90480, 96380, 96381
When multiple vaccines are given same date by same provider, bill the administration add-on codes (90461, 90472, or 90474) with the correct number of units

Documentation Required

Diagnosis code requirements for Rabies and Hepatitis B claims

For Medicare Part B and Commercial claims involving Rabies or Hepatitis B vaccines for individuals at high or intermediate risk, include the required diagnosis code on the claim. For Rabies place the diagnosis code in the first position.

Rabies: Z20.3 (Contact with and (suspected) exposure to rabies) — place in first position on the claim for correct processing
Hepatitis B: Z23 (Encounter for immunization)

Note

Provider billing and member notification

For member-specific benefit questions or provider billing rules, contact the BCBSRI provider call center. Providers may not bill members for services determined not medically necessary or non-covered unless the member was informed and provided written agreement in advance per their participation agreement.

Contact provider call center for member-specific benefits and billing guidance
Do not bill members for non-covered or not medically necessary services unless prior written agreement obtained

Terms and code references

Immunization

DefinitionImmunization is the process of stimulating the body's immune system to protect against a specific infection by administering specially treated minute amounts of the bacteria or virus to elicit an immune response without causing disease.

Booster dosesSome immunizations require booster or repeat doses to maintain protection.

State supply noteRhode Island DOH provides certain biologicals to physician offices and hospital pharmacies at no charge for eligible residents per DOH distribution guidelines.

Add-on administration codes (90461, 90472, 90474)

Codes included90461, 90472, 90474

PurposeThese are administration add-on codes for each additional vaccine/toxoid component or additional intranasal/oral vaccine when multiple vaccines are given.

Usage noteWhen multiple vaccines are administered on the same date by the same provider, use these add-on codes and report units used on the claim.

Z23 and Z20.3 diagnosis codes

Z23Z23 — Encounter for immunization (use with applicable CPT vaccine codes)

Z20.3Z20.3 — Contact with and (suspected) exposure to rabies (for rabies claims; place in first diagnosis position)

Claim processing noteFor Medicare Part B and Commercial, use these diagnosis codes with Rabies or Hepatitis B vaccine claims as required for correct claims processing.

Participation agreement

DefinitionParticipation agreement — the contractual agreement between the provider and BCBSRI that governs billing, member notification, and other terms of participation.

Member billing restrictionProviders may not charge members for services determined not medically necessary or non-covered benefits unless the member was informed and agreed in writing in advance per the participation agreement.

Reference actionRefer to your participation agreement for applicable provisions related to billing and member notification.