CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Immunization and Vaccination Payment and Claims Guidelines

This document governs payment, claims filing, and coverage guidance for immunizations and vaccinations for Blue Cross & Blue Shield of Rhode Island members, including Medicare (BlueCHiP for Medicare) and Commercial products; it addresses state-supplied vaccines, retail pharmacy program participation, and coding/administrative requirements.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyImmunization and Vaccination Payment and Claims Guidelines

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionDo not request prior authorization; prior authorization is not applicable.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

90460-90474Listed covered CPT vaccine administration codes

Part B / Part DPart B vs Part D distinction

State-suppliedState-supplied vaccines

~80+Vaccine CPT/HCPCS codes listed

6Administration CPT codes covered

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Coverage Criteria

inv-01: Coverage criteria

Coverage varies by product and vaccine. Specific Medicare Part B vaccines and CDC/FDA-recommended vaccines are covered as described below; refer to member benefit documents for group-specific variations.

ALL of the following

ANY of the following
- Pneumococcal pneumonia (Part B)
- Influenza virus (Part B)
- Hepatitis B for individuals at high or intermediate risk (requires ICD-10 diagnosis code Z23)
- Tetanus and other vaccines directly related to treatment of an injury or direct exposure to disease/condition (e.g., rabies — requires ICD-10 diagnosis code Z20.3).
Documentation requirement for injury/exposure-related vaccines
Claims for tetanus vaccine coverage under Part B must be filed with a diagnosis indicating the vaccine was needed due to an injury.

ALL of the following

Vaccinations/immunizations are covered when recommended by CDC and AAP and when FDA guidelines are met.
Group/contract benefit variation
Benefits may vary by group/contract; refer to the Evidence of Coverage/Benefit Booklet for applicable benefits.

ALL of the following

State of Rhode Island Department of Health provides biologicals for pediatric immunizations; BCBSRI does not reimburse providers for DOH-supplied vaccines; BCBSRI follows DOH guidance for state-supplied vaccine lists and shortages.

ALL of the following

Providers must submit both the administration procedure code and the vaccine/toxoid procedure code when the provider purchases the vaccine.
Submit modifier 22 to identify vaccines supplied by the physician (non-state-supplied) to facilitate pricing that includes allowance for the vaccine.

ALL of the following

E/M services should not be filed with immunization unless separately identifiable; use modifier 25 to report a separately identifiable E/M.

ALL of the following

BlueCHiP for Medicare plans do not cover travel-related vaccines; travel clinic counseling is typically noncovered for Commercial products (codes 99401-99404, 99411-99412) — members may be billed and must be notified.

ALL of the following

Part D generally covers vaccines not reimbursed under Medicare Parts A or B; providers may contact the Part D plan to inquire about coverage and supply supporting information to facilitate beneficiary vaccine coverage.

ALL of the following

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

inv-02: Coverage criteria by product

Coverage is defined by explicit lists of CPT/HCPCS codes and by product (BlueCHiP for Medicare vs Commercial). Some codes are excluded or pending FDA approval.

ALL of the following

Listed CPT/HCPCS codes include (examples shown in policy): 90630, 90653-90676, 90682-90689, 90694, 90714-90756, Q2034-Q2038.
Diagnosis code requirements for specific Part B vaccines
When billing Rabies or Hepatitis B for individuals at risk, include ICD-10 diagnosis codes Z20.3 (rabies exposure) or Z23 (encounter for immunization) as applicable.

ALL of the following

Listed CPT/HCPCS codes include (policy examples): 90476-90477, 90581, 90587, 90619-90699, 90700-90756, Q2034-Q2039, 90749; includes travel vaccine CPTs and a broad set of pediatric and adult immunizations.

Coding and Billing

BlueCHiP for Medicare - Covered CPT/HCPCS Vaccine/Toxoid CodesmixedCovered

90630	Influenza virus vaccine; quadrivalent (IIV4), split virus, preservative free, for intradermal use
90653	Influenza virus vaccine, inactivated, subunit, adjuvanted, for intramuscular use
90654	Influenza virus vaccine, trivalent (IIV3) split virus, preservative-free, for intradermal use
90655	Influenza virus vaccine, trivalent (IIV3), split virus, preservative free, 0.25 mL dosage, for intramuscular use
90656	Influenza virus vaccine, trivalent (IIV3), split virus, preservative free, 0.5 mL dosage, for intramuscular use
90657	Influenza virus vaccine, trivalent (IIV3), split virus, 0.25 mL dosage, for intramuscular use
90658	Influenza virus vaccine, trivalent (IIV3), split virus, 0.5 mL dosage, for intramuscular use
90660	Influenza virus vaccine, trivalent; live (LAIV3), for intranasal use
90661	Influenza virus vaccine, trivalent (ccIIV3), derived from cell cultures, subunit, preservative and antibiotic free, 0.5 mL dosage, for intramuscular use
90662	Influenza virus vaccine (IIV), split, preservative enhanced immunogenicity via increased antigen content; for intramuscular use

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Commercial Products - Covered CPT/HCPCS Vaccine/Toxoid CodesmixedCovered

90476	Adenovirus vaccine, type 4, live, for oral use
90477	Adenovirus vaccine, type 7, live, for oral use
90581	Anthrax vaccine, for subcutaneous use
90587	Dengue vaccine, quadrivalent; live, 3 dose schedule, for subcutaneous use
90619	Meningococcal conjugate vaccine, serogroups A, C, W, Y, quadrivalent; tetanus toxoid carrier (MenACWY-TT), for intramuscular use
90620	Meningococcal recombinant protein and outer membrane vesicle vaccine, serogroup B (MenB-4C), 2 dose schedule, for intramuscular use
90621	Meningococcal recombinant lipoprotein vaccine, serogroup B (MenB-FHbp), 2 or 3 dose schedule; for intramuscular use
90630	Influenza virus vaccine; quadrivalent (IIV4), split virus, preservative free, for intradermal use
90632	Hepatitis A vaccine (HepA), adult dosage, for intramuscular use
90633	Hepatitis A vaccine (HepA), pediatric/adolescent dosage-2 dose schedule, for intramuscular use

1–10 of 72

1/8

Non-covered / Pending CodesCPTNot Covered

90666	Influenza virus vaccine (IIV), pandemic formulation, split virus, preservative free (pending FDA approval)
90667	Influenza virus vaccine (IIV), pandemic formulation, split virus, adjuvanted (pending FDA approval)
90668	Influenza virus vaccine (IIV), pandemic formulation, split virus (pending FDA approval)

Administration Add-on Units

Multiple vaccines on same dateWhen multiple vaccines are administered on the same date of service and by the same provider, file add-on administration codes (90461, 90472, 90474) and indicate the number of units used

Provider Actions and Requirements

Prior Authorization

Prior authorization not applicable

Prior authorization is not required for immunizations or vaccine administration under this policy.

Documentation Required

Part D coverage inquiry for non‑formulary vaccines

If a vaccine is not listed on a Part D plan formulary, providers may contact the Part D plan to inquire about coverage and provide any supporting information needed to facilitate beneficiary vaccine coverage.

Contact the member's Part D plan when the vaccine is not on the plan formulary.
Supply supporting documentation as requested to help establish medical necessity and enable reimbursement under Part D.

Definitions and Required Codes

State‑supplied vaccines (Rhode Island DOH)

DefinitionState‑supplied vaccines are biologicals provided by the Rhode Island Department of Health (DOH) for pediatric immunizations.

Reimbursement stanceBCBSRI does not reimburse providers for vaccines supplied by the Rhode Island DOH or any other state or federal agency.

DOH guidanceBCBSRI follows DOH guidelines for which vaccines are state‑supplied; refer to the DOH for lists and vaccine shortage information.

Program fundingBCBSRI is assessed a vaccine tax that is paid to the State to fund the DOH vaccine distribution program.

Modifier 22 for provider‑supplied (non‑state) vaccines

When to submit Modifier 22