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Immunization administration by intramuscular injection, severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) (coronavirus disease [COVID-19]) vaccine; each additional component administered (List separately in addition to code for primary procedure

Service Code
90481 (CPT) Immunization administration by intramuscular injection, severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) (coronavirus disease [COVID-19]) vaccine; each additional component administered (List separately in addition to code for primary procedure
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Immunization counseling by physician or other qualified health care professional when immunization(s) is not administered by provider on the same date of service; 3 minutes up to 10 minutes

Service Code
90482 (CPT) Immunization counseling by physician or other qualified health care professional when immunization(s) is not administered by provider on the same date of service; 3 minutes up to 10 minutes
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Immunization counseling by physician or other qualified health care professional when immunization(s) is not administered by provider on the same date of service; greater than 10 minutes up to 20 minutes

Service Code
90483 (CPT) Immunization counseling by physician or other qualified health care professional when immunization(s) is not administered by provider on the same date of service; greater than 10 minutes up to 20 minutes
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Immunization counseling by physician or other qualified health care professional when immunization(s) is not administered by provider on the same date of service; greater than 20 minutes

Service Code
90484 (CPT) Immunization counseling by physician or other qualified health care professional when immunization(s) is not administered by provider on the same date of service; greater than 20 minutes
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Chikungunya virus vaccine, live attenuated, for intramuscular use

Service Code
90589 (CPT) Chikungunya virus vaccine, live attenuated, for intramuscular use
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Influenza virus vaccine, trivalent, and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, 31.7 mcg/0.32 mL dosage, for intramuscular use

Service Code
90612 (CPT) Influenza virus vaccine, trivalent, and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, 31.7 mcg/0.32 mL dosage, for intramuscular use
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Influenza virus vaccine, quadrivalent, and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, 40 mcg/0.4 mL dosage, for intramuscular use

Service Code
90613 (CPT) Influenza virus vaccine, quadrivalent, and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, 40 mcg/0.4 mL dosage, for intramuscular use
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Meningococcal conjugate vaccine, serogroups A, C, W, Y, quadrivalent, tetanus toxoid carrier (MenACWY-TT), for intramuscular use

Service Code
90619 (CPT) Meningococcal conjugate vaccine, serogroups A, C, W, Y, quadrivalent, tetanus toxoid carrier (MenACWY-TT), for intramuscular use
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Meningococcal pentavalent vaccine, conjugated Men A, C, W, Y-tetanus toxoid carrier, and Men B-FHbp, for intramuscular use

Service Code
90623 (CPT) Meningococcal pentavalent vaccine, conjugated Men A, C, W, Y-tetanus toxoid carrier, and Men B-FHbp, for intramuscular use
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Meningococcal pentavalent vaccine, Men B-4C recombinant proteins and outer membrane vesicle and conjugated Men A, C, W, Y-diphtheria toxoid carrier, for intramuscular use

Service Code
90624 (CPT) Meningococcal pentavalent vaccine, Men B-4C recombinant proteins and outer membrane vesicle and conjugated Men A, C, W, Y-diphtheria toxoid carrier, for intramuscular use
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Tick-borne encephalitis virus vaccine, inactivated; 0.25 mL dosage, for intramuscular use

Service Code
90626 (CPT) Tick-borne encephalitis virus vaccine, inactivated; 0.25 mL dosage, for intramuscular use
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Tick-borne encephalitis virus vaccine, inactivated; 0.5 mL dosage, for intramuscular use

Service Code
90627 (CPT) Tick-borne encephalitis virus vaccine, inactivated; 0.5 mL dosage, for intramuscular use
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Influenza virus vaccine (IIV), H5, pandemic formulation, split virus, adjuvanted, for intramuscular use

Service Code
90631 (CPT) Influenza virus vaccine (IIV), H5, pandemic formulation, split virus, adjuvanted, for intramuscular use
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Influenza virus vaccine, H5N1, derived from cell cultures, adjuvanted, for intramuscular use

Service Code
90635 (CPT) Influenza virus vaccine, H5N1, derived from cell cultures, adjuvanted, for intramuscular use
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Human Papillomavirus vaccine types 6, 11, 16, 18, 31, 33, 45, 52, 58, nonavalent (9vHPV), 2 or 3 dose schedule, for intramuscular use

Service Code
90651 (CPT) Human Papillomavirus vaccine types 6, 11, 16, 18, 31, 33, 45, 52, 58, nonavalent (9vHPV), 2 or 3 dose schedule, for intramuscular use
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Immunization administration

Service Code
90670 (CPT) Pneumococcal conjugate vaccine, 13 valent (PCV13), for intramuscular use
Prior Authorization Required
No
Telehealth Billable
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Immunization is the process of making a person resistant to an infectious disease, typically by administering a vaccine. It stops severe illness, long-term disability, and death from dangerous diseases. High immunization rates create herd immunity, which protects babies and people who cannot get vaccinated. It is one of the most cost-effective public health tools available.

Immunizations may be administered in a variety of ways. Intramuscular (IM): A shot injected directly into a muscle, such as the arm or thigh. Subcutaneous (Subcut): A shot injected into the fatty layer of tissue right under the skin. Intranasal (NAS): A spray or mist delivered into the nostrils. Oral (PO): Liquid or drops swallowed through the mouth.

Limits

Hemodyalisis: Covered without documentation of medical necessity up to three times weekly. Cannot exceed more than one hemodialysis treatment per date of service.

For AKI dialysis treatments during the monthly billing cycle, only one payment for one treatment per day across settings is allowed; additional payment may be allowed for an uncompleted or partial treatment.

Providers shall document the first date of the ongoing dialysis treatment on each claim submitted.

Providers shall bill dialysis-related services once per calendar month using the last day of the month as the date of service.

If the beneficiary dies before month-end, use the date of death or the last date seen instead of the last day of the month.

Hemodialysis training is reimbursed in sessions that can last up to five hours per day.

Peritoneal Dialysis: Covered when provided by a Medicaid & Medicare certified ESRD hospital-based renal dialysis center or free-standing ESRD facility.

CAPD and CCPD are covered per date of service, not per treatment.

Providers shall bill dialysis-related services once per calendar month, using the last day of the month as the date of service.

Dialysis training is typically completed within two weeks of initiating self-care.

CAPD training sessions can last up to eight hours per day.

CCPD training sessions can last up to eight hours per day.

Home dialysis is performed at home by an ESRD beneficiary or private caregiver who has completed appropriate training.

Self Dialysis: Self-dialysis may be performed only in CMS-compliant centers or in the ESRD beneficiary's private primary residence.

Little or no professional assistance is provided except in an emergency.

Dialysis training is typically completed within two weeks of initiating self-care.

Hemodialysis training sessions can last up to 5 hours per day.

Reimbursement for the completed course is allowed once per beneficiary's lifetime.

Dialysis training sessions are limited to 25 sessions per beneficiary's lifetime.

Training and retraining sessions are reimbursed at the same rate.

Exclusions

Home dialysis is not covered for beneficiaries diagnosed with acute kidney injury because they require close medical supervision.

For undocumented aliens, dialysis is covered only as an emergency service in a facility with licensed professional monitoring during each episode of care; once the beneficiary is stable enough for in-home hemodialysis without immediate medical attention, the treatment is no longer an emergency service.

Medicaid shall not cover the following Dialysis Services:

  • a. office visits, home visits, consults and care plan oversight included in the

monthly capitation;

  • b. access maintenance performed by the staff in the ESRD facility;
  • c. take home drugs and supplies;
  • d. specimen collection fees;
  • e. transportation: The beneficiary is encouraged to contact their local county

Department of Social Services for assistance;

  • f. medical supply charges, including syringes and their administration;
  • g. costs associated with a private caregiver, outside of allowed training paid to

the training facility; and

  • h. capitation payment for the month in which the training code is billed.

Note: When a beneficiary becomes eligible for Medicare or another third-party payer, Medicaid cannot be billed as the primary payer.

Federal Qualified Health Centers and Rural Health Clinics may not provide dialysis services or any dialysis related services.

Place of Service

Home, ESRD facilities, and independent laboratories. Telehealth claims should be filed with the provider's usual place of services code(s). Co-payments Monthly co-payments are required for Dialysis Services.

How to Submit

N/A - No authorization is required

Resources

90715:TETANUS, DIPHTHERIA TOXOIDS AND ACELLULAR PERTUSSIS VACCINE (TDAP), FOR USE IN

Service Code
90715 (CPT) 90715:TETANUS, DIPHTHERIA TOXOIDS AND ACELLULAR PERTUSSIS VACCINE (TDAP), FOR USE IN
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

90732 PNEUMOCOCCAL POLYSACCHARIDE VACCINE, 23-VALENT, ADULT OR IMMUNOSUPPRESSED

Service Code
90732 (CPT) 90732 PNEUMOCOCCAL POLYSACCHARIDE VACCINE, 23-VALENT, ADULT OR IMMUNOSUPPRESSED
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Unlisted vaccine/toxoid

Service Code
90749 (CPT) Unlisted vaccine/toxoid
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

How to Submit

Please submit your request to Trillium Health Resources

Psychological Services Provided by Health Departments and School-Based Health Centers to the Under 21 Population

Service Code
90785 (CPT) Interactive complexity (List separately in addition to the code for primary procedure)
Prior Authorization Required
No
Benefit Plan
Medicaid
Age Group
All
Diagnosis Group
Intellectual/ Developmental Disability, Mental Health, Substance Use

Psychological services for children and adolescents are goal-directed interventions designed to enable children, adolescents, and their families to cope more effectively with complex problems. Services may include comprehensive psychosocial assessments and treatment planning, goal-directed psychotherapy (individual, group, or family), and referral to other mental health resources as needed. These services involve the identification of and intervention with children and adolescents who may be at risk for developing more serious emotional or behavioral problems as well as those who are already experiencing these problems.

Authorization Guidelines

Outpatient behavioral health services must be provided in accordance with the requirements and procedures documented in Clinical Coverage Policy 8C: Outpatient Behavioral Health Services Provided by Direct-Enrolled Providers and the applicable Trillium Benefit Plan.

Note: No medical referral is needed to access this service.

Unit Value

The appropriate procedure code(s) determines the billing unit(s).

Limits

The provider shall communicate and coordinate care with others providing care. When the member is receiving multiple BH services in addition to this service, a tx plan must be developed, and outpatient behavioral health services are to be incorporated into the tx plan.

Level of Care

Outpatient behavioral health services must be provided in accordance with the requirements and procedures documented in Clinical Coverage Policy 8C: Outpatient Behavioral Health Services Provided by Direct-Enrolled Providers and the applicable Trillium Benefit Plan.

How to Submit

N/A - No authorization is required

Resources