CMCS Connections

10 C M C S c o n n e c t i o n s 1 s t q u a r t e r 2 0 1 4 By Amanda Mizell T he Indiana State Department Health (ISDH) administers the federal Vaccines for Children (VFC) Program. ISDH provides free vaccines to providers to administer children 18 years old and under that meet one or more of the following criteria: • Enrolled in Medicaid • Without health insurance • Identified by parent or guardian as American Indian or Alaskan native • Underinsured, for example, children with health insurance that does not cover immunizations are eligible to receive VFC vaccines only in a Federally Qualified Health Center (FQHC) or a Rural Health Center (RHC). For the Indiana Health Coverage Program (IHCP), providers may bill the IHCP up to $8 for administering a VFC vaccine to any IHCP eligible ch i l d 1 8 y e a r s o l d o r y o u n g e r. IHCP reimbursement for VFC vaccine administration is the lesser of the provider's submitted charge for VFC vaccine administration or $8. To bill the IHCP for VFC vaccine administration use V20.2 as the primary diagnosis, the correct p r o c e d u r e c o d e w i t h a b i l l e d amount of $0.00 for the vaccine administered and the appropriate vaccine administration code with the SL modifier. For combined vaccines, bill the correct code for the combined vaccine and charge only one vaccine administration fee. • 90471 SL − Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); 1 vaccine (single or combination vaccine/toxoid); VFC vaccine administration. • 90472 SL − Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); each additional vaccine (single or combination vaccine/toxoid) (List separately in addition to code for primary procedure); VFC vaccine administration. • 90473 SL − Immunization administration by intranasal or oral route; 1 vaccine (single or combination vaccine/toxoid); VFC vaccine administration. • 90474 SL − Immunization administration by intranasal or oral route; each additional vaccine (single or combination vaccine/toxoid) (List separately in addition to code for primary procedure); VFC vaccine administration. When a VFC vaccine is administered by a nurse practitioner employed by physicians in a physician-directed group or clinic and not using his/her own NPI for billing, the codes above should be billed followed by the SA modifier (for example, 90471 SL SA) to identify the service is performed by a nurse practitioner. For additional details on billing procedures for VFC vaccine, please review the IHCP's provider manual Chapter 8 Page 384, which can be found at: provider.indianamedicaid. com/ihcp/manuals/chapter08.pdf. VFC: Vaccines For Children Program STANDARDS FOR ACCESS TO CARE FOR HOOSIER HEALTHWISE, INDIANA MEDICAID MEMBERS Member access to care for Medicaid members is established by the State of Indiana through contracts with the Managed Care Entities. Members often express frustration in getting a timely appointment for their healthcare needs. The access to care standards are published (right) for your reference. We appreciate all you do to promote the health and well- being of the Indiana Medicaid members and to provide care in a timely fashion! ACCESS STANDARDS FOR PMP VISITS appointment category appointment standards Urgent/Emergent Care Triage 24 hours/day Non-Urgent Symptomatic 72 hours Routine Physical Exam 3 months Initial Appt. (non-pregnant adult) 3 months Routine Gynecological Exam 3 months New Obstetrical Patient Within 1 month of calling for appt. Initial Appt. (well child) Within 1 month of calling for appt. Children with Special Health Needs 1 month ACCESS GUIDELINES FOR SPECIALIST VISITS appointment category appointment standards Emergency 24 hours Urgent 48 hours Non-Urgent Symptomatic 4 weeks

• Cover