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Network Matters
News and Information for the
Harvard Pilgrim Health Care Network

September 2016

Updated Policy: Vaccine and Immunization

After updating our Vaccine and Immunization Payment Policy in July, Harvard Pilgrim received feedback from providers about differences in how the states in our service area administer their immunization programs, which offer certain pediatric vaccines to providers free of charge.

For example, some state programs provide particular vaccines for free only to uninsured children, not all children. In several cases, the policy listed certain vaccines as state-supplied for members through age 18, when this was not always the case. After clarifying this with providers and the state vaccine programs, Harvard Pilgrim updated our Vaccine and Immunization Payment Policy to correct this information.

As a reminder, under our current policy, if a vaccine is available through the state’s immunization 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. 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 (a copy of the purchase invoice and proof from the state that the vaccine was unavailable).

All state-supplied vaccines should be billed with the SL modifier to indicate that the vaccine has been supplied by the state. However, 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.

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Eric H. Schultz,
President and Chief Executive Officer

Robert Farias,
Vice President, Network Services

Annmarie Dadoly,

Joseph O'Riordan,

Kristin Edmonston,
Production Coordinator