Clarification on Influenza A (H1N1) Virus Vaccine

Since an article regarding TRICARE coverage of Influenza A (H1N1) vaccinations was published on October 14, 2009, we have received requests for additional information.

Below is a chart comparing H1N1 vaccination coverage for TRICARE Prime, Standard, Extra and Prime Remote beneficiaries.

TRICARE Program	Influenza vaccination coverage	Vaccine location	Deductibles or cost-shares	Referral Required
Prime	Yes	Any network provider, military treatment facility (MTF), primary care manager (PCM), or non-network TRICARE-authorized provider office, clinic or retail setting	None	No except for active duty Service members (ADSMs)
Prime Remote	Yes	Any network provider, MTF, PCM, or non-network TRICARE-authorized provider office, clinic or retail setting	None	No
Standard/Extra	Yes	Any network provider,  PCM, or non-network TRICARE-authorized provider office, clinic or retail setting	None	No

Here are some additional important points regarding H1N1 influenza vaccination coverage:

• The United States government is providing the H1N1 vaccine at no cost to providers; therefore TRICARE will only reimburse providers for the administration of the vaccine. Beneficiaries should not be billed for the vaccine or required to pay in advance; they will have no cost-shares or copayments.
• Beneficiaries must obtain the vaccine from a TRICARE-authorized provider. H1N1 vaccines may be administered by a TRICARE-authorized provider office or clinic that uses nurses to administer the vaccines with a supervising physician. 

H1N1 Virus Vaccine Billing

Effective for dates of service on and after September 1, 2009, the Centers for Medicare & Medicaid Services (CMS) has created the following new codes for Influenza A (H1N1):

• G9141 – Influenza A (H1N1) immunization administration (includes the physician counseling the patient/family)
• G9142 – Influenza A (H1N1) vaccine, any route of administration
• 90470-H1N1 immunization administration (intramuscular, intranasal), including counseling when performed

The following code has also been revised to refer specifically to the H1N1 vaccine:

• 90663-Influenza virus vaccine, pandemic formulation, H1N1

Payment will be allowed for G9141 Influenza A (H1N1) immunization administration. The G9142 will be included on the Government No Pay List (GNPL) effective September 1, 2009. Providers do not need to bill the G9142 (HIN1 vaccine code) on their claim; however, if the G9142 is billed on the claim, only that claim line will be denied.

If an outpatient hospital dispenses the H1N1 vaccine, the facility should bill HCPCS code G9142 to follow the correct Outpatient Prospective Payment System (OPPS) requirements. If CPT code 90470 is billed, the line will be denied.

If you bill 90470 for the administration/counseling, you should also bill 90663 for the H1N1 vaccine even though CPT code 90663 will be denied since the government is providing the vaccine. TriWest will reimburse CPT code 90470 at the TRICARE maximum allowable rate (CMAC) for CPT code 90471.

For more information about the H1N1 flu, go to CMS’s dedicated Web site at http://www.flu.gov/faq/swineflu/ or the CDC's Web site at http://www.cdc.gov/H1N1FLU/.

Published Date: 10/23/2009