Harvard Pilgrim reimburses contracted providers for the provision of vaccine and immunization services. Each state in our service area administers an immunization program that offers certain pediatric vaccines to providers free of charge. Harvard Pilgrim, along with other health plans, provides funding to support these state programs.
As a result, under our current policy, if a vaccine is available through the state’s vaccine supply program, Harvard Pilgrim does not provide reimbursement for the vaccine for members under age 19. However, we will reimburse the provider for the administration fee.
Harvard Pilgrim is updating this Vaccine Payment Policy to include several vaccines that were made available through state vaccine programs in recent years (Hepatitis A, HPV, Meningococcal conjugate four-valent, Tdap, and Varicella) and to ensure that all state-supplied vaccines are included. For dates of service beginning July 1, 2016, Harvard Pilgrim will not reimburse the following state-supplied vaccines for members under the age of 19:
- Diphtheria, tetanus toxoids and acellular pertussis vaccine (DTaP)
- Diphtheria, tetanus toxoids for under age seven (DT)
- Haemophilus influenzae B vaccine (Hib)
- Diphtheria, tetanus toxoids, acellular pertussis vaccine, hepatitis-B and polio vaccine (DtaP-HepB-IPV)
- Hepatitis A vaccine
- Hepatitis B vaccine
- Human papilloma virus vaccine (HPV)
- Influenza virus vaccine
- Measles, mumps and rubella virus vaccine (MMR)
- Measles, mumps, rubella and varicella vaccine (MMRV)
- Meningococcal conjugate vaccine
- Meningococcal polysaccharide vaccine
- Pneumococcal conjugate vaccine
- Pneumococcal polysaccharide vaccine
- Poliovirus vaccine (IPV)
- Tetanus and diphtheria toxoids for ages 7 or older
- Varicella virus vaccine
All state-supplied vaccines should be billed with the SL modifier to indicate that the vaccine has been supplied by the state. However, as of July 1, 2016, Harvard Pilgrim will not reimburse the cost of any vaccine that can be supplied by the state even if the SL modifier is not used or in the cases where the provider has chosen not to participate in their state’s vaccine program. If a provider chooses to not participate in their state’s vaccine program, patients should be referred to a participating provider for vaccine administration.
If you are unable to receive a vaccine through the state program because that vaccine has been exhausted, Harvard Pilgrim will provide reimbursement under appeal with the appropriate documentation (copy of the purchase invoice and proof from the state that the vaccine was unavailable).
For more information, please refer to the Vaccine Payment Policy.