CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Immunizations and vaccinations payment and claims filing

Payment and claims filing guidelines for immunizations and vaccinations for pediatric and adult members of Blue Cross Blue Shield of Rhode Island; covers Medicare Advantage and Commercial products and providers billing in Rhode Island and out-of-state.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyImmunizations and vaccinations payment and claims filing

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date10|15|2007

Next Review DateN/A

Key ActionFor member-specific benefits or eligibility, call the provider call center; benefits and eligibility are determined by the member's subscriber agreement or employer agreement.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

IncludedPart B vaccine list

Not reimbursedState-supplied DOH biologics

Through 2024COVID-19 cost-share waiver

~150+Sample vaccine codes

3Admin HCPCS reimbursed (MA)

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Coverage rules and lists

Coverage rules summary

Coverage varies by product type (Medicare Advantage vs Commercial) and by whether vaccines are state‑supplied; specifics are summarized below.

ALL of the following

BCBSRI will continue to waive cost share for COVID‑19 immunizations through December 31, 2024 for Medicare Part B and for Commercial fully insured and municipal self‑funded employer groups per RI law.

Coverage listings and exclusions

Coverage lists and exclusions present in the document excerpts:

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ALL of the following

The source identifies specific immunization CPT codes that are non‑covered or contract exclusions as they are pending FDA approval (e.g., 90666, 90667).

ALL of the following

Refer to separate policies for unlisted procedures and rabies treatment coding where applicable; for Medicare Advantage and Commercial products follow the unlisted procedure process for codes such as 90749 and Q2039 as noted elsewhere in the policy materials.

CPT / HCPCS and administration coding

Administration CPTsCPTCovered

90460-90474,90480,96380-96381

Immunization administration codes (including counseling where indicated) and RSV monoclonal antibody administration

Part B vaccine/toxoid codesCPTCovered

90622,90626-90627,90630,90653-90662,90664,90670-90675,90677,90682-90689

Selected vaccine/toxoid CPT/HCPCS codes covered under Medicare Advantage Part B as listed

Sample covered vaccine CPT/HCPCS codes (see document for full list)CPTCovered

90654	Influenza virus vaccine, trivalent (IIV3) split virus, preservative-free, for intradermal or intramuscular use
90671	Pneumococcal conjugate vaccine, 15 valent (PCV15) (Effective 7/1/2021)
90732	Pneumococcal polysaccharide vaccine, 23-valent (PPSV23)
91318	SARS-CoV-2 mRNA LNP vaccine, 3 mcg/0.3 mL (one of multiple COVID-19 vaccine codes listed)

Non-covered / pending FDA approvalCPTNot Covered

90666	Influenza virus vaccine (IIV), pandemic formulation — listed as non-covered/contract exclusion pending FDA approval
90667	Influenza virus vaccine (IIV), pandemic formulation, adjuvanted — non-covered pending FDA approval

Referenced immunization CPTCPT

90636

CPT Code referenced in CMS article on immunizations

Multiple vaccines same date — Administration codes

Add-on administration codesUse CPT add-on administration codes 90461, 90472, 90474 for multiple vaccines given the same date by the same provider; indicate the number of units on the claim.

Primary administration codes90460, 90471, 90473, 90480, 96380-96381 are also defined for single-vaccine administration and RSV monoclonal antibody administration.

Counseling inclusionCodes 90460 and 96380/96381 include counseling by a physician or other qualified health care professional where indicated.

Oral/intranasal administration90473 and 90474 apply to intranasal or oral vaccine administration (one vaccine and each additional vaccine respectively).

Billing, documentation, and administrative actions

Prior Authorization

Prior authorization: Not applicable.

Billing Rule

Diagnosis codes required for Rabies and Hepatitis B claims

For Medicare Part B coverage and Commercial products, the following diagnosis codes are required to be submitted with the applicable CPT vaccine codes for Rabies and Hepatitis B when administered to individuals at high or intermediate risk. Rabies: ICD-10-CM Z20.3 (Contact with and (suspected) exposure to rabies). Note: for correct claims processing, place this diagnosis code in the first position on the claim form. Hepatitis B: ICD-10-CM Z23 (Encounter for immunization).

Rabies: Z20.3 — place in first position on claim
Hepatitis B: Z23 — Encounter for immunization

Terms and explanatory notes

Immunization — Definition

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 so they stimulate immunity without causing disease.

Booster dosesSome immunizations require booster or repeat doses of the same vaccine to maintain protection.

Medicare Part B contextThe background section notes that some vaccines are covered under Medicare Part B while others fall under Part D, affecting billing and benefits.

State‑supplied biologicals

State-supplied biologicals policyThe Rhode Island DOH provides biologicals for pediatric immunizations for RI residents; BCBSRI does not reimburse providers for biologics supplied by the DOH or other state/federal agencies.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyImmunizations and vaccinations payment and claims filing

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date10|15|2007

Next Review DateN/A

Key ActionFor member-specific benefits or eligibility, call the provider call center; benefits and eligibility are determined by the member's subscriber agreement or employer agreement.

SourceLink

On This Page

Effective dates for selected codes

PCV15 and PCV20 effective date90671 (PCV15) and 90677 (PCV20) effective 7/1/2021.

RSV vaccines effective date90678 and 90679 (RSV preF subunit vaccines) effective 10/1/2023.

General coding noteEffective dates for specific vaccine codes are stated in the coding listings and should be used as provided when filing claims.

CPT updates and external coding guidance

AMA CPT updates referencedAMA announced CPT updates for monkeypox testing and vaccination (see AMA press release).

COVID-19 vaccine code guidanceReferences to FDA changes simplify use of bivalent mRNA COVID-19 vaccines and AMA COVID-19 CPT vaccine and immunization code resources.

CMS billing referenceCMS article on billing and coding immunizations (includes mention of CPT code 90636) is cited for further coding guidance.

Billing Rule

Unlisted vaccine/toxoid coding process

For Medicare Advantage Plans and Commercial products, certain vaccine/toxoid codes are handled via the unlisted procedures process. Follow your standard unlisted procedure documentation and coding workflow when submitting claims for these codes.

90749 — Unlisted vaccine/toxoid
Q2039 — Influenza virus vaccine, not otherwise specified

Note

Member eligibility and benefits inquiry

Benefits and eligibility are determined by the member's subscriber agreement or employer agreement and may vary by subcategory. For member-specific benefits or eligibility inquiries, contact the provider call center. This policy is informational and is not a guarantee of payment.

Call provider call center for member-specific benefits and eligibility
Benefits/coverage determined by member's subscriber agreement or employer contract

BCBSRI follow DOH guidance

BCBSRI follows DOH guidance to determine which vaccines are state supplied and is assessed a vaccine tax to fund DOH distribution.

DOH resourceRefer to the Rhode Island DOH Pediatric and Adult State Supplied Vaccines publication for the list of state-supplied vaccines and shortage information.

HCPCS administration codes — Medicare Advantage reimbursement

HCPCS administration codesG0008 (Administration of influenza virus vaccine), G0009 (Administration of pneumococcal vaccine), and G0010 (Administration of hepatitis B vaccine) are separately reimbursed for Medicare Advantage Plans.

Reference to separate policyProviders should also refer to the Preventive Services for Medicare Advantage Plans policy for correct coding guidance.

ACIP — Advisory Committee on Immunization Practices

ACIP definition and resourceACIP — Advisory Committee on Immunization Practices; CDC ACIP vaccine recommendations are cited as the source for immunization guidance.

ACIP URLCDC ACIP recommendations available at http://www.cdc.gov/vaccines/hcp/acip-recs/index.html (referenced in policy).

Policy disclaimer and applicability

Informational natureThis medical policy is provided for informational purposes only and is not a guarantee of payment.

Benefits governed by member agreementsBenefits and eligibility are determined by the member's subscriber agreement, member certificate, or employer agreement, which supersede this policy.

Provider recourse for non-covered servicesIf services are non-covered or not medically necessary, providers may not charge members unless the member was informed and agreed in writing in advance.