Or. Admin. Code § 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 [File Link
Not Available] 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.
Notes
Tables referenced are available from the agency.]
Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.025 & 414.065
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