Some health plans may require you to bill the administration code AND the H1N1 vaccine code because their claim system rejects an administration code billed alone. You can bill 1 cent for the vaccine code to make sure your claim is paid. The Centers for Medicare & Medicaid Services (CMS) has approved this way of billing and does not consider it fraud.
Q. May physicians bill health insurance plans that require a charge of 1 cent for the vaccine in order to process claims, even though it is not permissible to charge for H1N1 vaccine?
A. Yes. CMS understands that billing software is complex and may require you to submit a nominal fee (1 cent) for the vaccine in order to process claims. However, you may not bill patients any fee for the vaccine, and you should warn them that the 1-cent fee may appear on their insurance statement.
Q. May physicians bill private third-party payers or insurers for H1N1 vaccine administration if the private insurer's payment level is greater than the regional Medicare vaccine administration rate?
A. Yes. However, you can bill payers and insurance plans at your regular agreed-upon rates and accept whatever level of payment they provide for H1N1 vaccine administration. You should consult each insurer's Web site for its specific billing requirements and payment policies.
Note that you may not request out-of-pocket payment from a patient that is greater than the amount Medicare pays for influenza vaccine administration in your region.
Source:H1N1 Vaccine Administration Billing Q&As
Other Reimbursement Links
- Aetna H1N1 Information
- Humana H1N1 information
- Tamiflu and Relenza Are Benefits of Texas Medicaid and the CSHCN Services Program (TMHP, Oct. 27, 2009)
- Texas Medicaid to Reimburse Administration Fee for H1N1 Vaccine (TMHP, Oct. 16, 2009)
- BCBS of Texas H1N1 Information (Oct. 9, 2009)
- UnitedHealthCare H1N1 Reimbursement Information ( PDF , Oct. 8, 2009)
- Medicare, Two Insurers Set H1N1 Flu Vaccine Payments ( TMA Practice E-tips , Sept. 21, 2009)
- Cigna H1N1 Information ( PDF , September 2009)
- H1N1 Health Insurer Coding Comparison Spreadsheet ( PDF , Spreadsheet Prepared by the AMA)
National Flu & PPV Biller Administration Codes Paid By Medicare
Effective Jan. 1, 2009 - Dec. 31, 2009
- Texas Brazoria County $19.99
- Dallas County $21.03
- Galveston County $20.41
- Harris County(Houston GPCI locality) $20.94
- Jefferson County(Beaumont GPCI locality) $19.24
- Tarrant County (Ft Worth GPCI locality) $20.28
- Travis County (Austin GPCI locality) $20.68
- Rest of Texas $19.20
TMA Influenza Resources