Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code G0009 (vaccine) billed for date of service March 15, 2022.
You asked the Plan to pay for this claim as billed. You say that this service should be covered by the Plan. The Plan denied your request. The Plan says Medicare billing criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated while the billing criteria used by Maximus is correct, the entire claim is not paid, just the cost of the shot given. Per Medicare Claims Processing Manual, Chapter 18 - Preventive and Screening Services, Section 10.2.2.2 - Special Instructions for Independent and Provider-Based Rural Health Clinics/Federally Qualified Health Center (RHCs/FQHCs): Independent and provider-based RHCs and FQHCs do not include charges for influenza virus, pneumococcal and COVID-19 vaccines on Form CMS-1450. Administration of these vaccines does not count as a visit when the only service involved is the administration of the vaccine. If there was another reason for the visit, the RHC/FQHC should bill for the visit without adding the cost of the influenza virus, pneumococcal or COVID-19 vaccines to the charge for the visit on the bill.
RHCs/FQHCs do not bill for a visit when the only service involved is the administration of the hepatitis B vaccine. As with other vaccines administered during an otherwise payable encounter, no line items specifically for this service are billed on the RHC/FQHC claims in addition to the encounter. Per the CMS MA Payment Guide for Out of Network Payments, Flu, hepatitis B, and pneumonia shots section: For both FQHCs and RHCs (see below) there are special rules related to MAO reimbursement to noncontracting and "deemed" providers when a flu, hepatitis B, or pneumonia shot is the only service provided. RHCs and FQHCs do not get paid the all-inclusive rate for flu, hepatitis B, or pneumococcal vaccines if they are the only service during a visit. However, the costs of these vaccines are included in the all-inclusive rate. If one visits an RHC or FQHC for a different covered service (regardless of whether or not they get a vaccine during the same visit), the all-inclusive rate is paid. But if the only service provided during a visit is one of these vaccines, then Medicare pays nothing for that visit. Under original Medicare, the plan keeps track of the vaccine costs on a log or roster. The roster is then submitted to the FI at the end of the year. At settlement, the FI looks at the total of the all-inclusive rates paid during the year, plus the vaccine costs reported on the roster. This sum represents the RHC's or FQHC's costs. The RHC or FQHC is then paid the difference between 80% of the lesser of (the per visit costs, or the national limit - except there is no limit for hospital based RHCs). In calculating the number of visits for the per visit costs, a visit that includes only a flu, hepatitis, or pneumonia shot does not count as an RHC or FQHC visit. Therefore, the all-inclusive rate is inflated to include these shots; but the rate is not paid when only the flu/hepatitis B/pneumonia shot is provided (and no other RHC or FQHC service is provided). MA plans are required to pay the cost for the shots only (as reflected on each facility's roster). This amount should be much less than the all-inclusive rate. Per the Medicare guidelines, the Plan has correctly declined the code for payment as the provider should be adding the charge to their roster they submit at the end of the year for settlement.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. In this case, this claim could not be paid as billed as due to the Medicare rules for rural health clinic services, only the single service is payable at a negotiated rate and not the entire claim. Medicare rules for coverage of this claim as billed have not been met. Therefore, we decided that the Plan does not have to pay for procedure code G0009 (vaccine) billed for date of service March 15, 2022.