July 22, 2021
Timely vaccinations can help protect your patients’ health. For patient safety, it’s important that you follow the U.S. Food and Drug Administration (FDA) guidelines and the Advisory Committee on Immunization Practices’ (ACIP) recommendations and Child and Adult Immunization Schedules.
How are claims affected?
Blue Cross and Blue Shield of New Oklahoma (BCBSOK) reviews claims to ensure applicable guidelines are met. We’ve found that two categories of vaccines are often administered outside FDA and ACIP recommendations: those to prevent human papillomavirus (HPV) and those to prevent shingles caused by the herpes zoster virus.
- For these categories, if vaccines are administered outside of the FDA and ACIP recommendations: Payment may be denied for services determined to be not Medically Necessary or Experimental/Investigational/Unproven, except as otherwise provided, or for lack of information, unless Hospital has obtained a Written Waiver prior to rendering services; and
- Recover reimbursements as per the claim payment recovery process outlined in our participating provider contracts.
BCBSOK will continue to reimburse medically necessary claims for vaccines administered according to FDA approval guidelines and ACIP recommended schedules.
Know the Facts: HPV Vaccination
Gardasil 9 (9vHPV) is the vaccine for the prevention of HPV infections and associated diseases, including oropharyngeal and other head and neck cancers.
- As of October 2018, the FDA approved Gardasil 9 for women and men ages 9 to 45.
- In June 2019, ACIP recommended catch-up vaccinations for women and men through age 26. ACIP also recommended vaccinating adults older than 26. Involve your patients in the decision to vaccinate. Find help for shared clinical decision-making here on our Provider web site.
- For patients between 9 and 14 years old, ACIP recommends two or three doses. For patients between 15 and 45 years old, ACIP recommends three doses.
- As reported by the Centers for Disease Control and Prevention (CDC), as of the end of 2016, Gardasil 9 is the only HPV vaccine available in the U.S. Please check your systems and processes to avoid using 2vHPV or 4vHPV billing codes.
Know the Facts: Shingles Vaccinations
Shingrix and Zostavax help prevent shingles and its complications:
- Shingrix is approved by the FDA. ACIP recommends Shingrix for people age 50 or older. It requires two doses. The second dose should be two to six months after the first.
- Zostavax is no longer available in the U.S. It was removed from the 2021 ACIP adult immunization schedule.
- In compliance with the FDA approval guidelines, BCBSOK considers Shingrix and Zostavax as medically necessary for anyone age 50 or older.
More Information
The summary of the ACIP changes to the adult immunization schedule are in the February 12, 2021, Morbidity and Mortality Weekly Report.
ACIP’s recommendations include immunization schedules for children and adolescents as well as adults, which can be found on the CDC website.
Also refer to BCBSOK’s Clinical Payment and Coding Policies for our Preventive Services Policy (CPCP006).
This material is for informational purposes only and is not a substitute for the independent medical judgment of a physician or other health care provider. Physicians and other health care providers are encouraged to use their own medical judgment based upon all available information and the condition of the patient in determining the appropriate course of treatment. References to third party sources or organizations are not a representation, warranty or endorsement of such organizations. Any questions regarding those organizations should be addressed to them directly.