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    v1.0.28
    OpenPayerPolicy UpdatesReimbursement/Payment PolicyHealthfirst Monkeypox Vaccine Reimbursement Policy…
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    CurrenthealthfirstofnewyorkPolicy PO-RE-098v1

    Monkeypox Vaccine Reimbursement

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    Defines Healthfirst of New York's reimbursement guidelines for the administration and billing of monkeypox (Mpox) vaccines for specified lines of business and applicable providers.

    Policy Summary
    Payerhealthfirstofnewyork
    PolicyMonkeypox Vaccine Reimbursement
    Policy CodePolicy PO-RE-098v1
    Change TypeNo material change
    Effective DateJul 26, 2022
    Last ReviewApr 15, 2024
    Next Review Date
    Key ActionProviders must use conventional administration codes when billing Healthfirst for vaccine administration; reimbursement follows provider contract or Healthfirst fee schedule and claims are subject to timely filing requirements.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    10+lines of business listed as covered
    90611,90622vaccine CPT/HCPCS codes referenced
    requiredtimely filing
    standard ratesadministration reimbursed

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    Coverage and Reimbursement Criteria

    Reimbursement criteria

    Covered when ALL of the following are met:

    Healthfirst will reimburse providers for administration of the Monkeypox (Mpox) vaccine according to standard reimbursement rates in the provider's contract or Healthfirst's standard fee schedule.
    Providers administering the Monkeypox vaccine must bill using conventional vaccine administration codes when submitting claims to Healthfirst.
    Claims for reimbursement are subject to timely filing requirements as set forth in the provider contract with Healthfirst and in the Healthfirst Provider Manual (see Provider Manual Subsection 17.6).
    Policy applies to multiple Healthfirst lines of business including Child Health Plus; Small/Individual Group (Commercial Plan); Essential Plan; Medicare PPO; Medicaid Managed Care; Integrated Benefits Dual Connection Plan; Health & Recovery Plan (HARP); Medicare Advantage; Medicaid Advantage Plus/MAP (Complete Care); Managed Long Term Care Partial Capitation Plan (MLTCP - Senior Health Partners); and Qualified Health Plan (QHP).

    Vaccine and Billing Codes

    Monkeypox/smallpox vaccine codesCPTCovered
    90611JYNNEOS (Imvamune or Imvanex) - Smallpox and Monkeypox vaccine, attenuated vaccinia virus, live, nonreplicating, preservative free, 0.5 mL dosage, suspension, for subcutaneous injection
    90622ACAM2000 - Vaccinia (smallpox) virus vaccine, live, lyophilized, 0.3 mL dosage, for percutaneous use
    Timely filing
    Timely filing requirementClaims for reimbursement are subject to timely filing requirements as set forth in the provider contract with Healthfirst and in the Healthfirst Provider Manual (see Provider Manual Subsection 17.6).
    Applies to provider claimsRequirement applies to claims submitted for administration of the monkeypox vaccine to be reimbursed under this policy.
    Reference locationHealthfirst Provider Manual Subsection 17.6 — 'Claims Inquiries, Corrected Claims, Claim Reconsideration, and Appeal Process'.
    Determines reimbursement eligibilityClaims not filed within the contractual timely filing period may be denied per provider contract terms.

    Billing and Claims Submission Guidance

    Billing Rule

    Billing and claims submission for monkeypox vaccine administration

    Providers must bill Healthfirst for monkeypox vaccine administration using conventional vaccine administration codes and follow the reimbursement rates in their provider contract or Healthfirst fee schedule. Claims are subject to timely filing requirements per the provider contract and Healthfirst Provider Manual Subsection 17.6.

    • Use conventional administration codes when billing Healthfirst for vaccine administration.
    • Reimbursement follows standard rates in the provider contract or Healthfirst fee schedule.
    • Claims are subject to timely filing requirements per provider contract and Healthfirst Provider Manual Subsection 17.6.

    Acronym Definitions

    CDC
    AcronymCDC
    DefinitionThe Centers for Disease Control and Prevention.
    Role in policyCDC provides the two no‑cost vaccines referenced in this policy (per source).
    FDA
    AcronymFDA
    DefinitionU.S. Food and Drug Administration.
    Role in policyFDA licensure is noted for the vaccines provided by CDC (JYNNEOS and ACAM2000).
    Policy Summary
    Payerhealthfirstofnewyork
    PolicyMonkeypox Vaccine Reimbursement
    Policy CodePolicy PO-RE-098v1
    Change TypeNo material change
    Effective DateJul 26, 2022
    Last ReviewApr 15, 2024
    Next Review Date
    Key ActionProviders must use conventional administration codes when billing Healthfirst for vaccine administration; reimbursement follows provider contract or Healthfirst fee schedule and claims are subject to timely filing requirements.
    SourceLink
    On This Page
    Coverage and Reimbursement CriteriaVaccine and Billing CodesBilling and Claims Submission GuidanceAcronym Definitions