Referring, ordering, prescribing or attending (ROPA) care providers will be required to register with AHCCCS for claims reimbursement and UnitedHealthcare Community Plan of Arizona has implemented this requirement into our claims processing guidelines.
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The Affordable Care Act (ACA) mandates that vaccine administration fees be paid to certain physicians and other providers administering vaccines to Medicaid-enrolled members, including those administered to children under the Vaccines for Children Program.
When a child (18 and under) receives a vaccine from VFC stock, Medicaid only pays for one administration fee regardless of if it is a single or combination vaccine. Medicaid does not pay for individual toxoids. The guidance references the CMS Final Rule and other sources which is a basis for this coverage.
When more than one vaccine is administered with counseling to a member (18 and under) each injection is reported with CPT code 90460 and SL modifier. Providers will be paid a separate fee for each injection. If more than one vaccine/toxoid is included in a single injection, AHCCCS will not make additional payment for administration of other additional toxoids included in the injection identified with CPT 90460.
The code descriptions for 90460 and 90461 are not specific for VFC so, in this case, the CMS Final Rule will control the claims submission and reimbursement for these administrations.
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Access the articles shared in the monthly network news brief emails. Arizona-specific information is identified along with the date the article was shared. Review this regularly to keep up to date on the Community Plan of Arizona updates and reminders.
For Medical Policies, Medical Benefit Drug Policies, Coverage Determination Guidelines, Utilization Review Guidelines and corresponding update bulletins for UnitedHealthcare Community Plan, visit the Policies and Protocols section.
Visit the Payment Policy Notifications page to view updates.
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