Provider Manual

Billing for flu vaccinations

Pre-authorization requirements for flu vaccines are waived for all members for out-of-network providers.
Self-funded plan coverage will vary by employer group, depending on purchase of coverage for general immunizations, flu shots and pharmacy benefits. Self-funded plans may also place additional restrictions on member use of out-of-network providers.
Coinsurance and out-of-network benefits may apply. Reference plan documents for details.
Vaccine shortages: In the event of a vaccine shortage, Priority Health will issue written guidelines and post them on this website. Note: A shortage is not the same as a delay from your vendor.

Key

VFC = Vaccines for Children program. You must obtain the vaccine from VFC program for Medicaid members under 19 years; administration covered by Priority Health. Report both the vaccine ($0 charge) and administration.
VFC only = Vaccine is NOT COVERED for adult Medicaid members

Flu vaccine coverage by plan effective 08/01/2011
Codes	Description	HMO/EPO, POS, PPO, MIChild	Medicaid	Medicare
90654	Influenza virus vaccine, split virus, preservative free, for intradermal use	Not covered	Not covered	Covered
90655	Influenza virus vaccine, split virus, preservative free, for children 6-35 months of age, for intramuscular use	Covered	VFC only	Covered by Medicare Advantage (Parts A&B) Not covered by Medigap or PriorityMedicare Rx (Part D)
90656	Influenza virus vaccine, split virus, preservative free, for use in individuals 3 years and above, for intramuscular use	Covered	Adults: Covered Children: VFC	Covered by Medicare Advantage (Parts A&B) Not covered by Medigap or PriorityMedicare Rx (Part D)
90657	Influenza virus vaccine, split virus, for children 6-35 months of age, for intramuscular use	Covered	VFC only	Covered by Medicare Advantage (Parts A&B) Not covered by Medigap or PriorityMedicare Rx (Part D)
90658	Influenza virus vaccine, split virus, for use in individuals 3 years of age and above, for intramuscular use	Covered	Adults: Covered Children: VFC	Not covered; use a vaccine-specific Q code.
90660	Influenza virus vaccine, live, for intranasal use Ages 2-49 years only	Covered	VFC	Covered by Medicare Advantage (Parts A&B) Not covered by Medigap or PriorityMedicare Rx (Part D)
90662	Influenza virus vaccine, split virus, preservative free, enhanced immunogenicity via increased antigen content, for intramuscular use Age 65 & older only	Covered	Covered	Covered by Medicare Advantage (Parts A&B) Not covered by Medigap or PriorityMedicare Rx (Part D)
Q2035	Afluria influenza virus vaccine, split virus, for use in individuals 3 years of age and above, for intramuscular use	Covered	VFC	Covered by Medicare Advantage (Parts A&B) Not covered by Medigap or PriorityMedicare Rx (Part D)
Q2036	Flulaval influenza virus vaccine, split virus, for use in individuals 3 years of age and above, for intramuscular use	Covered	VFC	Covered by Medicare Advantage (Parts A&B) Not covered by Medigap or PriorityMedicare Rx (Part D)
Q2037	Fluvirin influenza virus vaccine, split virus, for use in individuals 3 years of age and above, for intramuscular use	Covered	VFC	Covered by Medicare Advantage (Parts A&B) Not covered by Medigap or PriorityMedicare Rx (Part D)
Q2038	Fluzone influenza virus vaccine, split virus, for use in individuals 3 years of age and older, for intramuscular use	Covered	VFC	Covered by Medicare Advantage (Parts A&B) Not covered by Medigap or PriorityMedicare Rx (Part D)
Q2039	Not otherwise specified influenza virus vaccine, split virus, for use in individuals 3 years of age and older, for intramuscular use	Covered	VFC	Covered by Medicare Advantage (Parts A&B) Not covered by Medigap or PriorityMedicare Rx (Part D)
Flu vaccine administration coverage by plan
Administration codes	Description	HMO/EPO, POS, PPO, MIChild	Medicaid	Medicare
90460 90461 90471 90472 90473 90474	CPT codes for vaccine administration. (See description to select the most appropriate code)	Covered*	Covered*	Not covered*
90460 90461 90471 90472 90473 90474	*Office copay usually does not apply if vaccine administration is the only service rendered.
G0008	HCPCS code for seasonal flu vaccine administration for Medicare patients	Not covered**	Not covered**	REQUIRED for Medicare Advantage (Parts A&B) Not covered by Medigap or PriorityMedicare Rx (Part D)
G0008	**Office copay usually does not apply if vaccine administration is the only service rendered.

Seasonal flu vaccine coverage by location
Location	HMO or EPO	POS Preferred benefit for in-network providers Alternate benefit for out-of-network providers	PPO In-network benefit for in-network providers Out-of-network benefit for out-of-network providers	MIChild	Medicaid	Medicare
Physician office	Covered	Covered	Covered	Covered	Covered VFC restrictions apply	Covered by Medicare Advantage (Parts A&B) Not covered by Medigap or PriorityMedicare Rx (Part D)
Community clinics	Covered	Covered	Covered	Covered	Covered VFC restrictions apply	Covered by Medicare Advantage (Parts A&B) Not covered by Medigap or PriorityMedicare Rx (Part D)
Community clinics	In-network providers must bill us directly. Member cannot file a claim form for reimbursement. Out-of-network providers may bill or member can pay and file for reimbursement.
Home health care services	Covered if the health care organization contracts with us and bills us directly. The cost for administration is included in the cost of the nursing visit.
Health departments	Covered	Covered	Covered	Covered	Covered No member reimbursement; provider must bill VFC restrictions apply	Covered by Medicare Advantage (Parts A&B) Not covered by Medigap or PriorityMedicare Rx (Part D)
Health departments	In-network providers must bill us directly. Member cannot file a claim form for reimbursement. Out-of-network providers may bill or member can pay and file for reimbursement.
Pharmacies that participate in the Argus Vaccine Network (AVN)	Covered***	Covered***	Covered***	Covered	Covered for members age 19 and over	Covered by Medicare Advantage (Parts A&B) Not covered by Medigap or PriorityMedicare Rx (Part D)
	***Member must have prescription coverage. Pharmacy will bill us directly.
Pharmacies that don't participate in the AVN	Member can pay and file for reimbursement.
Urgent care centers	Covered	Covered	Covered	Covered	Covered VFC restrictions apply	Covered by Medicare Advantage (Parts A&B) Not covered by Medigap or PriorityMedicare Rx (Part D)
Urgent care centers	If the center contracts with Priority Health, it must bill us directly. Member cannot file a claim form for reimbursement. Out-of-network providers may bill or member can pay and file for reimbursement. Urgent care copay will not apply if only service is flu vaccine.
Work site flu clinic	Covered	Covered	Covered	Not applicable	Not applicable	Not applicable
Work site flu clinic	Covered if the provider contracts with Priority Health and bills us directly; member cannot file for reimbursement. Not covered if the employer has a discount arrangement with the provider (even if contracted) and the provider will be paid directly by the employer. Member cannot file a claim form for reimbursement.

Last modified: 1/5/2012

Provider Manual

Billing for flu vaccinations

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