This policy addresses reimbursement guidelines for vaccinations provided while inpatient at an acute facility.
A vaccine is a substance that helps protect against certain diseases.
Blue Cross Blue Shield of North Dakota (BCBSND) will pay outside of the All Patient Refined-Diagnosis Related Group (APR-DRG) for vaccinations, 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, 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.
Modifier SL- State Supplied Vaccinations
Created Inpatient Vaccinations policy from information published in HealthCare News Issue No. 383.