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Immunizations / Vaccinations
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This policy defines UnitedHealthcare's coverage stance for immunizations and vaccinations, including federally/state-mandated immunization benefits, plan-specific enhancements, covered and not-covered vaccines, and related definitions. It applies to UnitedHealthcare members governed by the payer's benefit plans and applicable state mandates.
Revised language pertaining to the California Health and Safety Code sections 1367.3 and 1367.35.
Coverage Criteria
Covered
Covered when ANY of the following apply:
See referenced state statutes and CDC/ACIP/AAP schedules.
Covered per UnitedHealthcare Preventive Care Services policy.
Refer to the Medical Policy titled Preventive Care Services for prior authorization/coverage details.
Contact Customer Service or refer to the member EOC/SOB.
Vaccines and immunizations provided solely for the purpose of international travel are not covered under this policy unless they are also recommended in UnitedHealthcare's current Medical Policy titled Preventive Care Services. Claims for travel-only vaccines should be verified against the Preventive Care Services policy before payment.
Services delivered under naturopathy are excluded: immunizations, vaccinations, injectable or intravenous infusions provided in naturopathic settings are not covered. The only exception is venipuncture for the purpose of obtaining blood samples for laboratory studies, which is not excluded.
Any vaccination that does not meet the policy's Covered Benefits criteria (for example, federal/state‑mandated immunizations, routine preventive immunizations per ACIP/CDC, medically necessary immunizations, or specific state market plan enhancements) is considered not covered and may be denied.
Provider Actions & Billing Guidance
Prior authorization — follow Preventive Care Services policy
Unless otherwise mandated, immunizations and vaccinations are covered in accordance with UnitedHealthcare's Preventive Care Services medical policy; prior authorization requirements (if any) are governed by that policy and the member's Evidence of Coverage/Schedule of Benefits.
Verify plan provisions and contact Customer Service as needed
Confirm plan-specific provisions in the member's EOC/SOB and follow the Preventive Care Services medical policy for coverage determinations; contact Customer Service for plan questions or discrepancies.
Documentation and eligibility verification
Verify the member's Evidence of Coverage (EOC) and Schedule of Benefits (SOB) to determine eligibility and plan-specific coverage (including state market plan enhancements such as TB screening); if the EOC/SOB conflicts with this policy, the EOC/SOB governs — contact Customer Service for clarification.
- Refer to the member's EOC/SOB for coverage, limitations and exclusions.
- Contact Customer Service to determine eligibility for state market plan enhancements (e.g., TB screening).
Coverage exclusions that may trigger denial
Claims for vaccines provided solely for travel, employment/education, insurance, marriage, adoption, immigration, camp, volunteer work, licensure/certification/registration, sports or recreational activities are not covered unless also recommended in the Preventive Care Services policy and may be denied.
- International travel–only vaccines are excluded unless recommended in Preventive Care Services.
- Vaccines required for employment or education are excluded unless recommended in Preventive Care Services.
- Other administrative-purpose vaccines (insurance, immigration, camp, licensure, sports, etc.) are excluded unless recommended in Preventive Care Services.
Background
Immunizations and vaccinations are preventive services intended to induce immunity against infectious disease. This policy aligns coverage with applicable federal and state mandates and with UnitedHealthcare's Preventive Care Services policy; vaccinations recommended only for nonmedical reasons (such as travel or administrative requirements) are generally excluded unless also recommended in the Preventive Care Services policy.
Definitions
References & Revision History
Revised language pertaining to California Health & Safety Code sections 1367.3 and 1367.35 and archived supporting information from previous policy version BIP085.N.
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