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November 2020

We’ve added Flumist to list of vaccines that can be administered by pharmacies for commercial members

This flu season we’ve added Flumist® (allV4) to the list of medical vaccines to be administered by pharmacies under CPT code *90694. Flumist® will also be added to the list of vaccines covered under our member’s pharmacy benefits, which can be billed under our claims processor, Express Scripts. These changes apply to Blue Cross Blue Shield of Michigan commercial and Blue Care Network commercial, non-Medicare members.

Review the complete list of Vaccine Affiliation Program payable vaccine codes
The following vaccines are included in the Vaccine Affiliation Program:

  • Seasonal flu
  • Pneumonia
  • Shingles
  • Human papillomavirus
  • Tetanus, diphtheria and pertussis
  • Meningitis
  • Cholera
  • Hepatitis A, B
  • Combination vaccines

A complete list of payable codes, including the associated administration codes, are available in the Vaccine Affiliation Program payable vaccine code document. Blue Cross and BCN review this document quarterly. Here’s how to find the latest version:

  1. Log in at bcbsm.com as a provider.
  2. Click on BCBSM Provider Publications and Resources.
  3. Click on Newsletters & Resources.
  4. Click on Health Reform Information and then click on List of Vaccine Affiliate Network payable vaccines for non-Medicare patients 2020.

Update vendor billing software
Pharmacies that administer vaccines paid through the member’s medical benefits need to instruct their vendors to update their billing software for our covered codes. If you don’t do so, the pharmacy technician may get a front-end rejection and the technician may notify the member that the vaccine is not covered in error.

Reminders on the process for vaccine administration
The process for administering vaccines hasn’t changed. Here are the recommended steps:

  1. Pharmacies should bill the Blue Cross and BCN member’s pharmacy coverage through our claims processor, Express Scripts. In many cases, vaccine claims will be covered through the pharmacy benefit.
  2. If you receive a point-of-sale rejection while billing a member’s pharmacy coverage, you’ll need to check the Blue Cross and BCN member’s medical eligibility and benefits using the instructions below. Once you’ve verified the members immunization benefits, you can submit your vaccine claim through the medical processes by following the instructions in the Medical Billing section of this document.

Note: Only pharmacies that are contracted with Blue Cross and BCN’s Vaccine Affiliation Program are eligible to submit claims as medical providers. If you’re a Michigan pharmacy that isn’t already participating in the Vaccine Affiliation Program, you can sign up. See How to sign up for the Vaccine Affiliation Program below.

  1. Submit the immunization record to the Michigan Health Information Network, or MIHIN, within three days of administration of vaccines.

Checking a member’s eligibility and benefits following medical processes
You can check member medical eligibility and benefits by phone or online.

Checking eligibility and benefits by phone:

  1. Call 1-800-344-8525.
  2. Say “benefits and eligibility.”
  3. Provide your BCBSM PIN or say, “I don’t have one.”
  4. Select prompt No. 9 for “other.”
  5. Enter the member’s enrollee ID (contract number).
  6. Enter the member’s date of birth.
  7. Say the first five letters of the member’s first name.
  8. Say “Cost share and benefits.”
  9. Say “Preventive services”to verify immunization benefits.

Checking eligibility and benefits online:

  1. Log in as a provider at bcbsm.com.
  2. Click on web-DENIS.
  3. Click on Subscriber Info, then click on Eligibility/Coverage/COB.
  4. Enter the member’s enrollee ID (contract number) and click on Enter.
  5. Look up benefits based on the type of coverage:

For PPO members with a national employer group:

For PPO members with a Michigan employer group:

For BCN HMO members:
  1. Select the member and click on MED under Detailed Benefits.
  1. Select the member and click on MED under Detailed Benefits, then click on Search.
  1. Click on the patient’s name, then click on Medical Benefits.
  1. Select your provider type from a drop‑down menu (select All other providers), then click on GO.
  1. In the quick view report tab, scroll down to Preventive Immunizations.
  1. Scroll down to Immunizations and look for any restrictions.
  1. Look under Immunizations to see if there are any specific benefit restrictions.
  1. Click on one of the immunizations links, then click on Included Codes for a list of the codes covered.
  1. Click on the code for more information, including coverage limitations and provider payment limitations for a list of provider types who can bill for the code.

Medical billing
Electronic billing tips for medical claims:

  • Use the 837 electronic CMS-1500.
  • Include your national provider identifier and immunization practice taxonomy code.
  • Report your NPI and your taxonomy code (261QH0100X).
  • Use location of service 60.
  • Bill the vaccine and the administration on the same claim, but on separate service lines, using the appropriate CPT or HCPCS codes.

Medical reimbursement
Please refer to the provider portal for the list of payable immunizations and fee schedules

Note: Fee revisions, new codes added after publishing and entire fee schedules are published on web-DENIS.  

How to sign up for the Vaccine Affiliation Program
If you’re a Michigan pharmacy not participating in the Vaccine Affiliation Program you can sign up at bcbsm.com:

  • Go to bcbsm.com/providers.
  • Click on Join our Network, scroll down to Step 3 and click on Enroll now.
  • Click on the button next to Physicians and Professionals, then click on Next.
  • Click on the button next to Enroll a new provider, then click on Next.
  • Under Allied Providers, click on the button next to Vaccine Pharmacy, then click on Next.
  • Complete and return the documents on this page.

Where to find help

General questions about medical vaccines – If you have general questions, call Provider Inquiry at 1-800-344-8525. To reach a Customer Service representative call between 8:30 a.m. and 5 p.m. Monday through Friday.

Electronic transactions – For help with electronic transactions, such as the 270/271 eligibility and benefit inquiry transaction, contact the Electronic Data Interchange Help Line at 1-800-542-0945 or e-mail EDICustMgmt@bcbsm.com.

Issues not resolved – If you can’t get your issue resolved through the above methods, the pharmacy provider consultant for all Michigan pharmacies may be able to help.

Contact: Charlie Bono
Email: cbono@bcbsm.com
Phone: 231-941-6012
Fax: 855-236-1219

Reminder: Pharmacies can bill for COVID-19 testing
We explained how pharmacies can bill for COVID-19 testing in an October Record article and a provider alert posted Aug. 31. In case you missed the earlier communications, here are links to COVID-19 testing documents for pharmacies:

For commercial members (Blue Cross and BCN)
For Medicare Advantage members (Medicare Plus Blue℠ and BCN Advantage℠)

No portion of this publication may be copied without the express written permission of Blue Cross Blue Shield of Michigan, except that BCBSM participating health care providers may make copies for their personal use. In no event may any portion of this publication be copied or reprinted and used for commercial purposes by any party other than BCBSM.

*CPT codes, descriptions and two-digit numeric modifiers only are copyright 2019 American Medical Association. All rights reserved.
Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and
independent licensees of the Blue Cross and Blue Shield Association.