In products where members are able to self-refer to providers for care and services, members are advised to use participating providers in order to receive the highest level of benefits.When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.
For more information on how Claim Payment Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.
Centers for Medicare and Medicaid Services (CMS). 2012- 2013 Immunizers’ Question & Answer Guide to Medicare Part B, Medicaid and CHIP Coverage of Seasonal Influenza and Pneumococcal Vaccinations . [CMS Web site.] Available at: http://www.cms.gov/Medicare/Prevention/Immunizations/Downloads/2012-2013_Flu_Guide.pdf
Centers for Medicare and Medicaid Services (CMS). CMS Claims Processing Manual. Chapter 12 - Physicians/Nonphysician Practitioners. [CMS Web site]. Available at: http://www.cms.gov/manuals/downloads/clm104c12.pdf.
Centers for Medicare and Medicaid Services (CMS). MLN Matters Article. Article # SE1431 Revised. 2010 - 2011 Seasonal Influenza (Flu) Resources for Health Care Professionals2014-2015 Influenza (Flu) Resources for Health Care Professionals. [CMS Web site]. Available at: https://www.cms.gov/MLNMattersArticles/downloads/SE1031.pdf.
Centers for Medicare & Medicaid Services. How to Use the Medicare National Correct Coding Initiative (NCCI) Tools. Available at:http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/How-To-Use-NCCI-Tools.pdf.
G0009: Administration of pneumococcal vaccine
G0010: Administration of hepatitis B vaccine
Policy: 00.10.01ab:Services Paid Above Capitation for Health Maintenance Organization (HMO) and Health Maintenance Organization Point-of-Service (HMO-POS) Primary Care Providers
Policy: 03.00.06s:Modifier 25: Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the Same Day of the Procedure or Other Service
Policy: 03.00.08e:Modifiers XE, XS, XP, XU, and 59
Policy: 08.00.22m:Immune Prophylaxis for Respiratory Syncytial Virus (RSV)
Policy: 00.06.02ac:Preventive Care Services (AmeriHealth)