Policy
Blue Cross Blue Shield of North Dakota (BCBSND) will pay outside of the All Patient Refined-Diagnosis Related Group (APR-DRG) or per-diem for immunizations, such as flu and pneumonia, that are given to a member when they are inpatient in an acute facility.
When submitting a claim, providers should use the CMS-1500 Claim Form with a Place of Service (POS) of 21. When billing for a state supplied vaccine please refer to the Modifier SL- State Supplied Vaccinations policy for billing guidance.
Limitations and Exclusions
While reimbursement is considered, payment determination is subject to, but not limited to:
- Group or Individual benefit
- Provider Participation Agreement
- Routine claim editing logic, including but not limited to incidental or mutually exclusive logic, payment integrity edits and medical necessity
- Mandated or legislative required criteria will always supersede.
In instances where the provider is participating, based on member benefits, co-payment, coinsurance, and/or deductible shall apply.
Cross Reference
Modifier SL- State Supplied Vaccinations
History
Date
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Updates
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12/18/2020
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Created Inpatient Vaccinations policy from information published in HealthCare News Issue No. 383.
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2/25/2022
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Updated formatting.
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2/9/2023
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Performed annual review of policy.
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8/23/2023
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Updated the policy name to immunizations rather than vaccines to be more all-inclusive. Also added language regarding paying in outside of the inpatient per-diem.
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9/15/2024
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Policy annual review completed.
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