Refer to the current year’s Preventive Schedule for guidelines on the Provider Resource Center for when and how often the following immunizations are recommended. This schedule is a reference tool for planning preventive care, and lists items/services required under the Patient Protection and Affordable Care Act of 2010 (PPACA), as amended. It is reviewed and updated periodically based on the advice of the U.S. Preventive Services Task Force, laws and regulations and updates to clinical guidelines established by national medical organizations. Accordingly, the content of this schedule is subject to change. Specific needs for preventive immunizations may vary according to member’s personal risk factors.
Patient Protection and Affordable Care Act, as amended (PPACA) (Enacted 3/23/2010)
Comprehensive Guidelines supported by the Health Resources and Services Administration Bright Futures™American Academy of Pediatrics
Childhood Immunization Insurance Act (Act 35 of 1992)
Childhood Immunizations (Effective 11/21/1992)
Pennsylvania's Act 83 of 2002 (Effective 08/28/2002)
The following mandated immunizations are covered for the insured, the insured spouse, or a dependent child in accordance with the age limits of the individual contracts and CDC/ACIP recommendations.
0041A |
0042A |
0044A |
90375 |
90376 |
90377 |
90380 |
90381 |
90460 |
90471 |
90480 |
90584 |
90587 |
90611 |
90619 |
90620 |
90621 |
90623 |
90630 |
90632 |
90633 |
90634 |
90636 |
90644 |
90647 |
90648 |
90649 |
90651 |
90653 |
90654 |
90655 |
90656 |
90657 |
90658 |
90660 |
90661 |
90662 |
90670 |
90671 |
90672 |
90673 |
90674 |
90677 |
90678 |
90679 |
90680 |
90681 |
90682 |
90683 |
90684 |
90685 |
90686 |
90687 |
90688 |
90694 |
90696 |
90697 |
90698 |
90700 |
90702 |
90703 |
90707 |
90710 |
90713 |
90714 |
90715 |
90716 |
90723 |
90732 |
90733 |
90734 |
90739 |
90740 |
90743 |
90744 |
90745 |
90746 |
90747 |
90748 |
90750 |
90756 |
91304 |
91318 |
91319 |
91320 |
91321 |
91322 |
96380 |
96381 |
J1560 |
M0201 |
Q2034 |
Q2035 |
Q2036 |
Q2037 |
Q2038 |
Q2039 |
|
Other Non-Mandated Immunizations
Other than those specific childhood immunizations listed above, coverage for immunizations is determined according to individual or group customer benefits. Immunizations should be reported under the appropriate procedure code. Immunization is acceptable for the following diseases:
Immunizations or injections for diseases other than those listed above are not eligible for payment. Immunizations must be FDA approved to be eligible for payment.
90585 |
90625 |
90630 |
90632 |
90647 |
90648 |
90653 |
90662 |
90670 |
90673 |
90674 |
90675 |
90676 |
90688 |
90690 |
90691 |
90694 |
90713 |
90716 |
90717 |
90732 |
90738 |
90739 |
90749 |
90750 |
|
|
|
NOTE: In addition to the above criteria, product specific dosage and/or frequency limits may apply in accordance with the U.S. Food and Drug Administration (FDA)-approved product prescribing information, national compendia, Centers for Medicare and Medicaid Services (CMS) and other peer reviewed resources or evidence-based guidelines. Highmark may deny, in full or in part, reimbursement for utilization that does not fall within the applicable dosage and/or frequency limits.
NOTE: A separate evaluation & management (E&M) code can be reported in addition to the administration of an immunization if a significant, separately identifiable E&M service is performed and documented in the individual's medical records. To justify these services, the individual's records must contain sufficient documentation regarding the appropriateness of performing both services, and documentation that the key components of the E&M service have been met. If the reported E&M service does not meet the component requirements, it will not be eligible for reimbursement. Payment for the immunization and the E&M service will also be subject to coverage limitations specified within the individual member's contract.
Refer to medical policy I-20 Immune Prophylaxis for Respiratory Syncytial Virus (RSV) for additional information.
Refer to medical policy I-14 Immune Globulin Therapy for additional information.
Refer to medical policy V-37 Autism Spectrum Disorders for additional information.
This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical or other circumstances may warrant individual consideration, based on review of applicable medical records, as well as other regulatory, contractual and/or legal requirements.
Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.
Highmark retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.
Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:
If you need these services, contact the Civil Rights Coordinator.
If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475
, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697
(TDD)
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
This information is issued by Highmark Blue Shield on behalf of its affiliated Blue companies, which are independent licensees of the Blue Cross Blue Shield Association. Highmark Inc. d/b/a Highmark Blue Shield and certain of its affiliated Blue companies serve Blue Shield members in the 21 counties of central Pennsylvania. As a partner in joint operating agreements, Highmark Blue Shield also provides services in conjunction with a separate health plan in southeastern Pennsylvania. Highmark Inc. or certain of its affiliated Blue companies also serve Blue Cross Blue Shield members in 29 counties in western Pennsylvania, 13 counties in northeastern Pennsylvania, the state of West Virginia plus Washington County, Ohio, the state of Delaware[ and [8] counties in western New York and Blue Shield members in [13] counties in northeastern New York]. All references to Highmark in this document are references to Highmark Inc. d/b/a Highmark Blue Shield and/or to one or more of its affiliated Blue companies.
Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.
Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:
If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
