016.06.05 Ark. Code R. 069

Current through Register Vol. 49, No. 9, September, 2024

Rule 016.06.05-069 - Hospital / Critical Access Hospital (CAH)/ End Stage Renal Disease (ESRD) Provider Manual Update Transmittal #84; Physician / Independent Lab / CCRNA / Radiation Therapy Center Provider Manual Update Transmittal #104; Nurse Practitioner Provider Manual Update Transmittal #60; Certified Nurse Midwife Provider Manual Update Transmittal #67

Section II Physician/Independent Lab/CRNA/Radiation Therapy Center

292.598 Influenza Virus Vaccine

A. Procedure code 90655, influenza virus vaccine, split virus, preservative free, for children 6 to 35 months, is currently covered through the VFC program. Claims for Medicaid beneficiaries must be filed using modifiers EP and TJ. When filing paper claims, use type of service 6 with modifiers EP and TJ.

ForARKids First-B beneficiaries, use modifier TJ. When filing paper claims, use type of service 1 with modifier TJ.

B. Effective for dates of service on and after October 1, 2005, Medicaid will cover procedure code 90656, influenza virus vaccine, split virus, preservative free, for ages 3 years and older.

1. For individuals under 19 years of age, claims must be filed using modifiers EP and TJ. When filing paper claims, use type of service 6 with the modifiers.

2. ForARKids First-B beneficiaries, use modifier TJ. When filing paper claims, use type of service 1 with the modifier.

3. For individuals ages 19 and older, no modifier is necessary and type of service 1 must be used when filing paper claims.

C. Effective for dates of service on and after October 1, 2005, procedure code 90660, influenza virus vaccine, live, for intranasal use, is covered. Coverage is limited to healthy individuals ages 5 through 49 who are not pregnant.

1. When filing claims for children 5 throughl 8 years of age, use modifiers EP and TJ. When filing paper claims, use type of service 6 with the modifiers.

2. ForARKids First-B beneficiaries, the procedure code must be billed using modifier TJ. When filing paper claims, use type of service 1 with the modifier.

3. No modifier is required for filing claims for beneficiaries ages 19 through 49. Paper claims require type of service 1.

D. Procedure code 90657, influenza virus vaccine, split virus, for children ages 6 through 35 months, is covered. Modifiers EP and TJ are required. Paper claims require type of service 6 with the modifiers.

ForARKids First-B beneficiaries, use modifier TJ. When paper claims are filed, use type of service 1 with the modifier.

E. Procedure code 90658, influenza virus vaccine, split virus, for use in individuals ages 3 years and older, will continue to be covered.

1. When filing paper claims for individuals under age 19, use type of service 6 with modifiers EP and TJ.

2. For ARKids First-B beneficiaries, use modifier TJ. For paper claims, use type of service 1 with the modifier.

3. No modifier is required for filing claims for beneficiaries aged 19 and older. Use type of service 1 when filing paper claims.

292.599 New Pharmacy Therapeutics and Radiopharmaceutical Therapy

A. New pharmacy and therapeutic agents are covered with prior approval from the Division of Medical Services Medical Director.

1. Claims must be submitted to EDS on paper.

2. Each claim must reflect, in the description of service field, the number in the treatment series of each administration for which you are billing Medicaid.

3. No prior authorization number is issued; therefore, a copy of the Medical Director's approval letter must be attached to each claim filed.

Refer to section 244.100 for coverage information and instructions for requesting prior approval.

B. Radiopharmaceutical therapy is covered with prior approval from the Medical Director of the Division of Medical Services. Claims must be filed using procedure code 79403.

1. Claims must be submitted to EDS on paper.

2. A copy of the Medical Director's approval letter and a copy of the invoice for the monoclonal antibody used must be attached to the claim form.

Refer to section 244.200 for coverage information and instructions for requesting prior approval.

SUBJECT: Provider Manual Update Transmittal #60

Section II Nurse Practitioner

252.449 Influenza Virus Vaccine

A. Procedure code 90655, influenza virus vaccine, split virus, preservative free, for children 6 to 35 months, is currently covered through the VFC program. Claims for Medicaid beneficiaries must be filed using modifiers EP and TJ. When filing paper claims, use type of service 6 with modifiers EP and TJ.

ForARKids First-B beneficiaries, use modifier TJ. When filing paper claims, use type of service 1 with modifier TJ.

B. Effective for dates of service on and after October 1, 2005, Medicaid will cover procedure code 90656, influenza virus vaccine, split virus, preservative free, for ages 3 years and older.

1. For individuals under 19 years of age, claims must be filed using modifiers EP and TJ. When filing paper claims, use type of service 6 with the modifiers.

2. ForARKids First-B beneficiaries, use modifier TJ. When filing paper claims, use type of service 1 with the modifier.

3. For individuals ages 19 and older, no modifier is necessary and type of service N must be used when filing paper claims.

C. Effective for dates of service on and after October 1, 2005, procedure code 90660, influenza virus vaccine, live, for intranasal use, is covered. Coverage is limited to healthy individuals ages 5 through 49 who are not pregnant.

1. When filing claims for children 5 throughl 8 years of age, use modifiers EP and TJ. When filing paper claims, use type of service 6 with the modifiers.

2. ForARKids First-B beneficiaries, the procedure code must be billed using modifier TJ. When filing paper claims, use type of service 1 with the modifier.

3. No modifier is required for filing claims for beneficiaries ages 19 through 49. Paper claims require type of service N.

D. Procedure code 90657, influenza virus vaccine, split virus, for children ages 6 through 35 months, is covered. Modifiers EP and TJ are required. Paper claims require type of service 6 with the modifiers.

ForARKids First-B beneficiaries, use modifier TJ. When paper claims are filed, use type of service 1 with the modifier.

E. Procedure code 90658, influenza virus vaccine, split virus, for use in individuals ages 3 years and older, will continue to be covered.

1. When filing paper claims for individuals under age 19, use type of service 6 with modifiers EP and TJ.

2. For ARKids First-B beneficiaries, use modifier TJ. For paper claims, use type of service 1 with the modifier.

3. No modifier is required for filing claims for beneficiaries aged 19 and older. If claims are filed on paper, use type of service N.

SUBJECT: Provider Manual Update Transmittal #84

Section II

Hospital/Critical Access Hospital (CAH)/End Stage Renal Disease (ESRD)

272.500 Influenza Virus Vaccines

A. Procedure code 90655, influenza virus vaccine, split virus, preservative free, for children 6 to 35 months of age, is covered through the Vaccines for Children (VFC) program.

1. Claims for Medicaid beneficiaries must be filed using modifiers EP and TJ.

2. For ARKids First-B beneficiaries, use modifier TJ.

B. Effective for dates of service on and after October 1, 2005, Medicaid covers procedure code 90656, influenza virus vaccine, split virus, preservative free, for ages 3 years and older.

1. For children under 19 years of age, claims must be filed using modifiers EP and TJ.

2. For ARKids First-B participants, claims must be filed using modifier TJ.

3. For individuals aged 19 and older, no modifier is necessary.

C. Effective for dates of service on and after October 1, 2005, procedure code 90660, influenza virus vaccine, live, for intranasal use, is covered. Coverage is limited to healthy individuals ages 5 through 49 who are not pregnant.

1. When filing claims for children 5 throughl 8 years of age, use modifiers EP and TJ.

2. For ARKids First-B participants, the procedure code must be billed using modifier TJ.

3. No modifier is required for filing claims for beneficiaries ages 19 through 49.

D. Procedure code 90657, influenza virus vaccine, split virus, for children ages 6 through 35 months, is covered.

1. Modifiers EP and TJ are required.

2. For ARKids First-B beneficiaries, use modifier TJ.

E. Procedure code 90658, influenza virus vaccine, split virus, for use in individuals aged 3 years and older, will continue to be covered.

1. When filing paper claims for Medicaid beneficiaries under age 19, use modifiers EP and TJ.

2. For ARKids First-B participants, use modifier TJ.

3. No modifier is required for filing claims for beneficiaries aged 19 and older.

SUBJECT: Provider Manual Update Transmittal #67

272.443 Influenza Virus Vaccine

A. Effective for dates of service on and after October 1, 2005, Medicaid will cover procedure code 90656, influenza virus vaccine, split virus, preservative free, for ages 3 years and older.

1. For individuals under 19 years of age, claims must be filed using modifiers EP and TJ. When filing paper claims, use type of service 6 with the modifiers.

2. ForARKids First-B beneficiaries, use modifier TJ. When filing paper claims, use type of service 1 with the modifier.

3. For individuals ages 19 and older, no modifier is necessary and type of service 9 must be used when filing paper claims.

B. Procedure code 90658, influenza virus vaccine, split virus, is covered for beneficiaries of certified nurse-midwife services.

1. For individuals under 19 years of age, claims must be filed using modifiers EP and TJ. When filing paper claims, use type of service 6 with the modifiers.

2. ForARKids First-B beneficiaries, use modifier TJ. When filing on paper, use type of service 1 with the modifier.

3. For individuals ages 19 and older, no modifier is necessary and type of service 9 must be used when filing paper claims.

016.06.05 Ark. Code R. 069

11/4/2005