Arkansas Administrative Code › Agency 016 - DEPARTMENT OF HUMAN SERVICES › Division 06 - Medical Services › Rule 016.06.06-053 - Child Health Services / Early and Periodic Screening, Diagnosis, and Treatment Update Transmittal #78

Current through Register Vol. 49, No. 6, June, 2024
215.110
Immunization Record
The child's immunization status should be assessed from the
				child's health record. If the child needs any immunization at the time of the
				screening, the immunization(s) will be administered as part of the screening
				process.
Immunizations for childhood diseases are exempt from primary
				care physician (PCP) referral requirements.
The Arkansas Medicaid program recommends that EPSDT providers
				follow the immunization schedule shown in the attached chart established by the
				Advisory Committee on Immunization Practices (ACIP), the American Academy of
				Pediatrics (AAP) and the American Academy of Family Physicians (AAFP).
The current immunization schedule indicates the recommended
				ages for routine administration of currently licensed childhood vaccines, as of
				December 1, 2005, for children through age 18 years. Providers may access the
				original chart at
www.cdc.gov/nip/acip
and follow the
				links to "childhood immunizations."
Click here
				to view image
Click here
				to view image
242.140
Vaccines for Children Program
The Vaccines for Children (VFC) Program was established to
				generate awareness and access for childhood immunizations. To enroll in the VFC
				Program, contact the Arkansas Division of Health. Providers may also obtain the
				vaccines to administer from the Arkansas Division of Health.
View or print Arkansas Division of Health contact
				information.
Vaccines available through the VFC program are covered for
				Medicaid-eligible children. Only the administrative fee is reimbursed. When
				filing claims for administering VFC vaccines,
providers must use the CPT procedure code for the vaccine
				administered. Electronic and paper claims require modifiers EP and TJ. When
				filing
paper claims,
type of service code "6" and the modifiers EP
				and TJ must be entered on form DMS-694.
View or print a
				DMS-694 sample claim form.
Medicaid policy regarding immunizations for adults remains
				unchanged by the VFC program.
Providers may consult the Physician's manual to view the
				list of vaccines that are non-VFC but are covered for beneficiaries who are 19
				and 20 years of age.
The following list contains the vaccines available
				through the VFC program.
* Effective for dates of service on and after March 1, 2006 **
				Effective for dates of service on and after July 10, 2006
Procedure Code
M1
M2
Age Range
Vaccine Description
90633*
EP
TJ
12 months-18 years
Hepatitis A vaccine, pediatric/adolescent dosage-2 dose
						  schedule, for intramuscular use
90634*
EP
TJ
12 months-18 years
Hepatitis A vaccine, pediatric/adolescent dosage-3 dose
						  schedule, for intramuscular use
90636
EP
TJ
18 years only
Hepatitis A and hepatitis B vaccine (HepA-HepB), adult
						  dosage, for intramuscular use
90645
EP
TJ
0-18 years
Hemophilus influenza b (Hib) HbOC conjugate (4 dose
						  schedule) for intramuscular use
90646
EP
TJ
0-18 years
Hemophilus influenza b (Hib) PRP-D conjugate for
						  booster use only, intramuscular use
90647
EP
TJ
0-18 years
Hemophilus influenza b (Hib) PRP-OMP conjugate (3 dose
						  schedule), for intramuscular use
90648
EP
TJ
0-18 years
Hemophilus influenza b vaccine (Hib), PRP-T conjugate
						  (4 dose schedule), for intramuscular use
90655
EP
TJ
6 months-35 months
Influenza virus vaccine, split virus, preservative
						  free, for children 6-35 months of age, for intramuscular use
90656
EP
TJ
3 years-18 years
Influenza virus vaccine, split virus, preservative
						  free, for use in individuals 3 years and above, for intramuscular
						  use
90657
EP
TJ
6 months-35 moths
Influenza virus vaccine, split virus, for children 6-35
						  months of age, for intramuscular use
90658
EP
TJ
3 years-18 years
Influenza virus vaccine, split virus, for use in
						  individuals 3 years and above, for intramuscular use
90660
EP
TJ
5 years-18 years (not pregnant)
Influenza virus vaccine, live, for intranasal
						  use
90669
EP
TJ
0-4 years
Pneumococcal conjugate vaccine polyvalent, for children
						  under 5 years, for intramuscular use
90680**
EP
TJ
6 weeks to 32 weeks
Rotavirus vaccine, pentavalent, 3 dose schedule, live,
						  for oral use
90700
EP
TJ
0-6 years
Diphtheria, tetanus toxoids and acellular pertussis
						  vaccine (DTaP), for use in individuals younger than 7 years, for intramuscular
						  use
90707
EP
TJ
0-18 years
Measles, mumps and rubella virus vaccine (MMR), live,
						  for subcutaneous use
90710*
EP
TJ
0-18 years
Measles, mumps, rubella, and Varicella vaccine (MMRV),
						  live, for subcutaneous use
90713
EP
TJ
0-18 years
Poliovirus vaccine, inactivated (IPV), for subcutaneous
						  or intramuscular use
90714
EP
TJ
7-18 years
Tetanus and diphtheria toxoids (Td) adsorbed,
						  preservative free, for use in individuals 7 years or older, for intramuscular
						  use
90715*
EP
TJ
7-18 years
Tetanus, diphtheria toxoids and acellular pertussis
						  vaccine (Tdap), for use in individuals 7 years or older, for intramuscular
						  use
90716
EP
TJ
0-18 years
Varicella virus vaccine, live, for subcutaneous
						  use
90718
EP
TJ
7-18 years
Tetanus and diphtheria toxoids (Td) absorbed for use in
						  individuals 7 years or older, for intramuscular use
90721
EP
TJ
0-18 years
Diphtheria, tetanus toxoids and acellular pertussis
						  vaccine and Hemophilus influenza B vaccine (DtaP-Hib), for intramuscular
						  use
90723
EP
TJ
0-18 years
Diphtheria, tetanus toxoids and acellular pertussis
						  vaccine, Hepatitis B, and poliovirus vaccine , inactivated (DTaP-HepB-IPV)( for
						  intramuscular use
90734*
EP
TJ
0-18 years
Meningococcal conjugate vaccine, serogroups A, C, Y and
						  W-135 (tetravalent), for intramuscular use
90743
EP
TJ
0-18 years
Hepatitis B vaccine, adolescent (2 dose schedule), for
						  intramuscular use
90744
EP
TJ
0-18 years
Hepatitis B vaccine, pediatric/adolescent (3 dose
						  schedule), for intramuscular use
90747
EP
TJ
0-18 years
Hepatitis B vaccine, dialysis or immunosuppressed
						  patient dosage (4 dose schedule), for intramuscular use
90748
EP
TJ
0-18 years
Hepatitis B and Hemophilus influenza b vaccine
						  (HepB-Hib), for intramuscular use