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Childhood Immunizations Coverage - Clarification
UnitedHealthcare wishes to clarify an article about childhood immunizations that appeared in the Protocols Update section of the January 2009 Network Bulletin. The statements in that article apply to childhood immunizations administered to Medicaid beneficiaries.
While UnitedHealthcare has many different benefit designs, our standard Certificate of Coverage (COC) offers benefit coverage for preventive services in a physician office, including well child examinations and childhood immunizations.
According to the UnitedHealthcare vaccine policy, available for viewing on our physician portal, UnitedHealthcare covers vaccines that are (a) approved by the US Food and Drug Administration; (b) have recommendations of the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention (CDC) published in its Morbidity and Mortality Weekly Report (MMWR); and (c) are not explicitly excluded from coverage, e.g. vaccines for foreign travel.
For 2009 Child and Adolescent Vaccination Schedules, visit Cdc.gov/vaccines/recs/schedules/child-schedule.htm.
Fee Schedules
We make our fee schedules transparent to the physicians who contract with us. UnitedHealthcare uses four primary methods for development of vaccine fee schedules:
1) Proprietary Red Book Average Wholesale Price (AWP) at the CPT/HCPCS level. We purchase this information from our external vendor, Thomson Reuters.
2) Public domain Centers for Medicare and Medicaid Services (CMS) drug pricing. This was formerly referred to as Average Sale Price (ASP). The ASP nomenclature has been changed because in practice, CMS uses several different pricing standards in addition to ASP to populate its drug and vaccine pricing file.
3) RJ Health AWP and ASP at the CPT/HCPCS level. We purchase this information from our external vendor, RJ Health.
4) UnitedHealthcare Drug Pricing Initiative effective April 1, 2007: Fees by primary fee sources including AWP and CMS sometimes lagged behind the introduction of new vaccines and other injectable drugs approved by the FDA. This lag resulted in temporary "fee gaps" within our fee schedules and as a result, reimbursement to physicians based on the physician contract may have defaulted to a percent of billed charges. When that occurred, some physicians may have temporarily paid more for a vaccine than we reimbursed. However, with our new initiative, each quarter, UnitedHealthcare will identify all new vaccines that have been, or are soon expected to be, introduced in the marketplace along with their respective CPT/HCPCS codes. In the event that an AWP or CMS price has not yet been published, UnitedHealthcare will use available fee information, including National Drug Code (NDC)-based pricing, as the CPT/HCPCS code fee basis until an AWP or CMS fee is published. Once Thomson Reuters and CMS publish pricing information, their information will replace our interim fee.
The actual fee that UnitedHealthcare pays to a physician is listed in the Market Specific Payment Schedule (MSPS) that accompanies the physician's contract.
If you have questions above coverage of or reimbursement for childhood immunizations, please contact your Network Account Manager.
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If you do not contract directly with UnitedHealthcare, and
participate in our network through an arrangement in which we
"Lease" a network from some other entity, some of the information
provided in this communication may not be applicable to you
and/or impact you differently. If you have questions regarding
any of the information or need to better understand its impact on
you, please contact your local Network Account Representative.
Questions or Comments? Write to us at:
UnitedHealthcare, MN012-S117, P.O. Box 1459,
Minneapolis, MN 55440-1459. For more information,
visit our Web site unitedhealthcareonline.com
or call our telephone self-service system at:
1-877-842-3210.
We respect your right to privacy; visit our Web site to read our
Privacy Policy, Security Notice and Notice of Privacy
Policy and Practices.
UnitedHealthcare Services,
Inc., P.O. Box 1459, Minneapolis, MN 55440-1459.
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