Coverage Policies

Use the index below to search for coverage information on specific medical conditions.

Note: For Arkansas State or Public School employees, services subject to pre-authorization are managed by Active Health Management, as noted in their Summary Plan Description.

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Medical Providers: Payment for care or services is based on eligibility, medical necessity and available benefits at time of service and is subject to all contractual exclusions and limitations, including pre-existing conditions if applicable.

Future eligibility cannot be guaranteed and should be rechecked at time of service. Verify benefits by signing into My Account or calling Customer Service at 800.235.7111 or 501.228.7111.

If not specified in a QualChoice coverage policy (Benefit Interpretation), QualChoice follows care guidelines published by MCG Health.

QualChoice reserves the right to alter, amend, change or supplement medical policies as needed. QualChoice reviews and authorizes services and substances. CPT and HCPCS codes are listed as a convenience and any absent, new or changed codes do not alter the intent of the policy.

INDEX:
A B C D E F G H I J K L M N O P Q R S T U V W X Y Z

Effective Date: 11/13/2003 Title: Flu Immunizations
Revision Date: 01/01/2019 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, 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. Non-standard immunizations (recombinant-DNA derived preparations), require prior authorization and are only indicated with a history of anaphylaxis (severe allergic reaction).  

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)    The use of recombinant DNA derived influenza vaccine (90673, 90682) or unspecified flu vaccine (Q2039) requires prior authorization and is only indicated with a history of anaphylaxis. 

3)    90660, 90664, and 90672 (Intranasal flu vaccinations) are covered if a flu shot is not the preferred option.

4)    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

IIV4 VACC INACTIVATED PRSRV FR 0.25ML DOS IM USE

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.
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