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Billing for flu vaccinations

Special circumstances not covered in the chart below:

  • No authorization is required for in-network providers and PPO providers.
  • Self-funded plan coverage will vary by employer group, depending on purchase of immunization and/or flu shot coverage.
  • Coinsurance may apply.
  • Vaccine shortages: In the event of a vaccine shortage, Priority Health may make exceptions to the coverages listed here; we will issue written guidelines in that case and post them on this website. Note: A shortage is not the same as a delay from your vendor.
  • Employer-required vaccinations: Priority Health does not cover any vaccine required for employment (e.g., for health care workers).

Key
  • GL = Recommended in the Preventive Health Care Guidelines; patient's deductible (if applicable) will be waived. Deductible will apply for vaccines not listed in the guidelines.
  • VFC = Covered by Vaccines for Children program (you must use the VFC program for members under 19 years)
Jump down to Coverage by location


Flu Shot Coverage by Plan
Codes Description HMO/EPO, POS,
PPO, MIChild
(self-funded plans will
differ by employer)
Medicaid Medicare
(all plans)
90655   GL
Influenza virus vaccine, split virus, preservative free,
for children 6-35 months of age,
for intramuscular use
Covered VFC Not covered
90656   GL Influenza virus vaccine, split virus, preservative free,
for use in individuals 3 years and above,
for intramuscular use
Covered
Adults:  Covered
Children: VFC
Covered
90657  GL Influenza virus vaccine, split virus,
for children 6-35 months of age,
for intramuscular use
Covered VFC Covered
90658   GL Influenza virus vaccine, split virus,
for use in individuals 3 years of age and above,
for intramuscular use
Covered Adults:  Covered
Children: VFC
Covered
90660  GL Influenza virus vaccine, live,
for intranasal use
Ages 2-49 years only
Covered VFC Covered
Administration CPT codes to use for vaccine administration.
Usually, an office copay does not apply if administration is the only service rendered.
90465-90474 90465-90474 G0008
Diagnosis Diagnosis codes:
Use V06.6 when billing combination influenza/pneumococcal vaccines.
V04.8
V06.6
V06.8
V70.0
V04.8
V06.6
V06.8
V70.0
N/A


Coverage by Location
Location Fully funded plans; MIChild
Self-funded plans

Employers may customize these plans and not cover flu shots.
Medicaid
Medicare
(all plans)
Physician office HMO: Covered for in-network providers
POS: Covered at Preferred benefit level for in-network providers and at Alternate benefit level for out-of-network providers
PPO: Covered at In-Network level for in-network providers and at Out-of-Network level for out-of-network providers
MIChild: Covered for in-network providers
EPO: Covered for in-network providers only
POS: Same as fully funded
PPO: Same as fully funded
Covered Covered
Home health care (includes community clinics)
  • Covered if contracted with Priority Health and billed directly
  • Intranasal vaccine not covered
  • Administration charge included with nursing visit
  • Covered if contracted with Priority Health and billed directly
  • Intranasal vaccine not covered
  • Administration charge included with nursing visit
  • Covered for adults only if contracted with Priority Health and billed directly
  • Administration charge included with nursing visit
  • Covered if contracted with Priority Health and billed directly (In-network)
Health departments Not covered Not covered VFC (children) Not covered


Last modified 11/12/08