|
|
|
|
Effective Date: 11/13/2003 |
Title: Flu Immunizations
|
|
Revision Date: 12/01/2020
|
Document: BI010:00
|
CPT Code(s): 90460, 90461, 90471, 90472, 90473, 90474, 90630, 90653-90658, 90660-90662, 90664, 90666-90668, 90672-90674, 90682, 90685-90689, 90694, 90756, Q0239
|
Public Statement
|
|
Effective Date:
a)
This policy will apply to
all services performed on or after the above Revision date which will become the
new effective date.
b)
For all services referred
to in this policy that were performed before the revision date, contact customer
service for the rules that would apply.
1)
Flu Immunizations are a covered preventive benefit, both for adults and
for children.
2)
Standard flu shots may be obtained from a network pharmacy at no member
cost share subject to the limitations of this medical policy.
3)
Standard flu immunizations (trivalent, quadrivalent, with or without
preservatives, intradermal or intramuscular) or intranasal flu vaccines
administered by a network provider are covered in full.
4)
We strongly encourage network providers to participate in the Arkansas
State Immunization registry (WebIZ) and to submit all immunization data.
|
Medical Statement
|
|
1)
QualChoice follows the recommendations of the Center for Disease Control
(CDC) to determine coverage of flu vaccines.
2)
90660, 90664, and 90672 (Intranasal
flu vaccinations) are covered if a flu shot is not the preferred option.
3)
90662, high dose flu
vaccine (Fluzone) is covered for members 65 and over
only.
We
strongly encourage network providers to participate in the Arkansas State
Immunization registry (WebIZ) and to submit all immunization data.
Codes
Used In This BI:
|
90460
|
Immunization (up to 18 yo) admin any route w physician/HCP counseling, 1
vaccine
|
|
90461
|
Immunization (up to 18 yo) admin any route w physician/HCP counseling,
each add’l vaccine
|
|
90471
|
Immunization admin via injection; 1 vaccine
|
|
90472
|
Immunization admin via injection; ea. addt`l vaccine
|
|
90473
|
Immunization admin via intranasal or oral route; 1 vaccine
|
|
90474
|
Immunization admin via intranasal or oral route; ea. addt`l vaccine
|
|
90630
|
Flu
vaccine, quadrivalent (IIV4), split virus, presrv free, ID
|
|
90653
|
Flu
vaccine, inactivated (IIV), IM
|
|
90654
|
Flu
vaccine, no preserv, ID
|
|
90655
|
Flu
vaccine, no preserv, 0.25 mL
|
|
90656
|
Flu
vaccine, no preserv, 0.5 mL
|
|
90657
|
Flu
vaccine, 0.25 mL, IM
|
|
90658
|
Flu
vaccine, 0.5 mL, IM
|
|
90660
|
Flu
vaccine, nasal
|
|
90661
|
Flu
virus vaccine (ccIIV3), derived frm cell cultures, subunit,
presrv/antibi free, IM
|
|
90662
|
Flu
vacc, prsv free, inc antig
|
|
90664
|
Flu
virus vaccine, live (LAIV), pandemic formulation, intranasal
|
|
90666
|
Flu
virus vaccine (IIV), pandemic formulation, presrv free, IM
|
|
90667
|
Flu
virus vaccine (IIV), pandemic formulation, split virus, presrv free, IM
|
|
90668
|
Flu
virus vaccine (IIV), pandemic formulation, split virus, IM
|
|
90672
|
Flu
vaccine, nasal, quadrivalent
|
|
90673
|
Flu
virus vaccine, trivalent (RIV3), derived frm recombinant DNA,
hemagglutinin (HA) protein only, presrv/antibi free, IM
|
|
90674
|
Influenza virus vaccine, quadrivalent (ccIIV4), derived from cell
cultures, subunit, preservative and antibiotic free, 0.5 mL dosage, IM
(new code 1/1/17)
|
|
90682
|
Flu
virus vaccine, quad (RIV4), derived from recombinant DNA, hemagglutinin
(HA) protein only, presrv/antibiotic free, IM (new code 1/1/17)
|
|
90685
|
Quadrivalent flu vaccine, preservative free 0.25 mL
|
|
90686
|
Quadrivalent flu vaccine, preservative free, 0.5 mL
|
|
90687
|
Quadrivalent flu vaccine, 0.25 mL
|
|
90688
|
Quadrivalent flu vaccine, 0.5 mL
|
|
90689
90694
|
IIV4 VACC
INACTIVATED PRSRV FR 0.25ML DOS IM USE
90694 - AIIV4 VACC INACTIVATED PRSRV FR 0.5ML DOS IM USE, ages 65 and
older (new code eff 01/01/2020)
|
|
90756
|
(1/1/2018)
Influenza vaccine quadrivalent (ccIIV4) from cell cult, antibi free .5ml
|
|
Q2039
|
Influenza vaccine
not otherwise specified
|
|
Application to Products
|
|
This policy applies to all health plans and
products administered by QualChoice, both those insured by QualChoice and those
that are self-funded by the sponsoring employer, unless there is indication in
this policy otherwise or a stated exclusion in your medical plan booklet.
Consult the individual plan sponsor Summary Plan Description (SPD) for
self-insured plans or the specific Evidence of Coverage (EOC) or Certificate of
Coverage (COC) for those plans or products insured by QualChoice. In the event
of a discrepancy between this policy and a self-insured customer’s SPD or the
specific QualChoice EOC or COC, the SPD, EOC, or COC, as applicable, will
prevail. State and federal mandates will be followed as they apply.
|
|
Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.
|
|