OAR 410-130-0255: Immunizations, Vaccines for Children, and Immune Globulins

(1) The Division covers immunizations as recommended by the Advisory Committee on Immunization Practices (ACIP) and approved by the Oregon Immunization Program. The approved ACIP recommendations are found in Guideline Note 106 of the Health Evidence Review Commission’s Prioritized List of Health Services as referenced in OAR 410-141-0520, http://www.oregon.gov/OHA/HPA/CSI-HERC/Pages/Prioritized-List.aspx . (2) Providers shall follow the (ACIP) guidelines for immunization schedules. Exceptions include: (a) On a case-by-case basis, provider may use clinical judgment in accordance with accepted medical practice to provide immunizations on a modified schedule, and; (b) On a case-by-case basis, provider may modify immunization schedule in compliance with the laws of the State of Oregon, including laws relating to medical and non-medical exemptions for immunizations. (3) Providers are encouraged to administer combination vaccines when medically appropriate and cost effective. (4) Providers must use standard billing procedures for adults and for any vaccines that are not part of the Vaccines for Children (VFC) Program. (5) Vaccines for Children (VFC) is a federal program that provides vaccine serums at no cost to providers for clients ages 0 through 18. All vaccines for this age group and for conditions covered by the VFC program must be obtained through the VFC program. The Division will not reimburse providers for the administration or purchase of privately purchased vaccines if the vaccine could have been obtained through the VFC program. For information about the VFC program or to enroll as a VFC provider, contact the Public Health Immunization Program. The Oregon VFC program website can be located at http://public.health.oregon.gov/PreventionWellness/VaccinesImmunization/ImmunizationProviderResources/vfc/Pages/index.aspx (6) The Division will only reimburse for the administration, not the serum, of vaccines available for free through the VFC Program. Refer to the 12/24/2013 Current Oregon Immunization Program State-Supplied Vaccine Billing Codes table available at http://bit.ly/1c3T6zy for a list of vaccines provided through the VFC Program. (7) To receive reimbursement for vaccine administration, VFC program providers must bill the Division: (a) With the appropriate vaccine common procedural terminology (CPT) code included; (b) Including the appropriate modifier -SL or -26; and (c) Reporting the vaccine administration in addition to an Evaluation and Management service (e.g., well-child visit) if provided on the same date of service; (8) For clients with private insurance, providers may bill the Division or the client’s managed care or coordinated care organization (MCO/CCO) directly for the administration of VFC vaccines. Medicaid and CHIP are not considered the “payer of last resort” for administration of VFC vaccines. (9) In compliance with Section 1202 of the Affordable Care Act ,VFC providers who qualify for the federal primary care rate increase as specified under 42 Code of Federal Regulation (CFR) 447 Subpart G (see also OAR 410-130-0005) are eligible for reimbursement for the administration of VFC vaccines at the Regional Maximum amount: (a) Effective 1/1/2013 the Regional Maximum amount is $21.96. (b) For providers that have met the federal primary care definition, MCO and CCOs are required to reimburse the lessor of: (A) The Regional Maximum administration fee, or (B) Medicare 2014 RVU and 2009 conversion factor amount. (c) MCO and CCOs are not required to reimburse the Regional Maximum amount to providers that have not met the federal primary care definition but may at their option. (d) For all fee for service providers, the Division reimburses the Regional Maximum amount for the administration of VFC vaccines. (10) The Division covers immune globulins based on the Prioritized List of Health Services. Synagis (palivizumab-rsv-igm) is covered with prior authorization only for high-risk infants and children. Refer to Guideline Note 69 of the Health Evidence Review Commission’s List of Prioritized Services as referenced in OAR 410-141-0520, http://www.oregon.gov/OHA/HPA/CIS-HERC/Pages/Prioritized-List.aspx and Oregon Medicaid Fee-For-Service Prior Authorization Approval Criteria as referenced in 410-121-0040, www.oregon.gov/OHA/HSD/OHP/Pages/Policy-Medical-Surgical.aspx . [ED. NOTE: Tables referenced are available from the agency.]