How should providers bill administration fees for VFC vaccines administered to children who are covered by Medicaid and have another form of health coverage?
Generally, providers are required to bill third parties before Medicaid will make payment (we refer to this as cost avoidance). However, there are a few exceptions to the cost avoidance rules. In the case of preventive pediatric services including EPSDT, if the Medicaid agency is billed, it is required to make payment and then seek reimbursement from the third party (CMS refers to this as pay & chase) – see 1902(a)(25)(E) of the Social Security Act. The Medicaid agency is to seek recovery as long as it is cost effective to do so, i.e., where the amount of reimbursement the State can reasonably expect to recover exceeds the cost of recovery (see 1902(a)(25)(B)). Since child immunizations fall under this exception, theprovider hasseveral options for billing the administration fee: Theprovider could administerVFC vaccine, and then bill the maximum regional charge for the vaccine administration to the Medicaid agency and Medicaid would be responsible for seeking reimbursement from the prim
Related Questions
- How should providers bill administration fees for VFC vaccines administered to children who are covered by Medicaid and have another form of health coverage?
- How will the change in CPT codes affect vaccine administration fees under the Vaccines for Children (VFC) program?
- Are all children who have Medicaid as a secondary insurance covered by VFC?
