Vaccinations Available for Respiratory Syncytial Virus Season

Download PDF

Bulletin

October 10, 2024, 9:50AM

To:

All Providers and Managed Care Organizations (MCOs) Participating in the Virginia Medical Assistance Program

From:

Cheryl J. Roberts, Director Department of Medical Assistance Services (DMAS)

The purpose of this bulletin is to inform providers of the vaccinations available for Respiratory Syncytial Virus (RSV) season (traditionally, October–March). Two new RSV vaccines have been approved by the Centers for Disease Control and Prevention’s (CDC) Advisory Committee on Immunization Practices (ACIP) committee for adults 60 years of age or older, based on discussions between the patient and their health care provider: Abrysvo [Pfizer] and Arexvy [GSK]. ACIP-recommended vaccines are covered by DMAS in accordance with Item 304.EEEE in the 2022 Appropriations Act and Item 288.ZZZ of the 2024 Appropriations Act.

One RSV monoclonal antibody preventive therapy (not a traditional vaccine) has been approved by ACIP for administration to infants and toddlers: Beyfortus (nirsevimab) [AstraZeneca/Sanofi].

Indications

Abrysvo & Arexvy: ACIP recommended one-time for adults 60 years of age or older “based on discussions between the patient and their health provider”.

Abrysvo: ACIP recommended for pregnant mothers once between 32-36 weeks gestation.

Beyfortus (nirsevimab): ACIP recommended for the following:

ALL infants <8 months old entering their first RSV season, AND
HIGH RISK children 8-19 months old entering their second RSV season

mResvia [Moderna]: ACIP recommended one-time for adults 60 years of age or older.

Coding/ Rates

PRODUCT

POPULATION

AGES

PRODUCT CODE(S)

PRODUCT TYPE

REIMBURSEMENT

ADMINISTRATIVE COMPENSATION

Arexvy*

Adult

60Y+

90679

Vaccine

See DMAS fee schedule

"When an immunization is the only service performed, an appropriate minimal
office visit (e.g., CPT/HCPCS code 99211), may be listed in addition to the injection." (FFS Manual)

Abrysvo*

Adult

60Y+

90678

Vaccine

See DMAS fee schedule

Pregnant Mothers (32-36wk gest)

>=19Y

90678

Vaccine

See DMAS fee schedule

<19Y

90678

Vaccine

Per VFC regs no compensation for cost of product.

No additional coding required/permissible.

mResvia

Adults

60Y+

90683

Vaccine

See DMAS fee schedule

"When an immunization is the only service performed, an appropriate minimal
office visit (e.g., CPT/HCPCS code 99211), may be listed in addition to the injection." (FFS Manual)

Beyfortus

Children

<19M

90380

90381

Monoclonal Antibody (mAb)

For mAb product, use administrative codes 96380 w/o counseling, 96381 w/counseling. No compensation for cost of product.

No additional coding required/permissible.

*Arexvy, Abrysvo and mResvia can also be obtained in pharmacy

To avoid disruption to claims payment through FFS and the MCOs providers must periodically check the DMAS provider portal, also known as the Provider Services Solution (PRSS), to ensure that the provider's enrollment, contact information, and license information is up to date, for all of the provider's respective service locations. Under federal rules, MCOs and DMAS are prohibited from paying claims to network providers who are not enrolled in PRSS. Additional information is provided on the MCO Provider Network Resources webpage and includes links to resources, tutorials and contact information to reach Gainwell with any provider enrollment or revalidation related questions. Dental providers should continue to enroll directly through the DMAS Dental Benefits Administrator, DentaQuest.

PROVIDER CONTACT INFORMATION & RESOURCES

Virginia Medicaid Web Portal Automated Response System (ARS)

Member eligibility, claims status, payment status, service limits, service authorization status, and remittance advice.

https://vamedicaid.dmas.virginia.gov/

Medicall (Audio Response System)

Member eligibility, claims status, payment status, service limits, service authorization status, and remittance advice.

1-800-884-9730 or 1-800-772-9996

Provider Appeals

DMAS launched an appeals portal in 2021. You can use this portal to file appeals and track the status of your appeals. Visit the website listed for appeal resources and to register for the portal.

https://www.dmas.virginia.gov/appeals/

Managed Care Programs

Cardinal Care Managed Care and Program of All-Inclusive Care for the Elderly (PACE). In order to be reimbursed for services provided to a managed care enrolled individual, providers must follow their respective contract with the managed care plan/PACE provider. The managed care plan may utilize different guidelines than those described for Medicaid fee-for-service individuals.

Cardinal Care Managed Care

https://www.dmas.virginia.gov/for-providers/managed-care/cardinal-care-…

PACE

Program of All-inclusive Care (virginia.gov)

Provider Enrollment

In-State: 804-270-5105

Out of State Toll Free: 888-829-5373

Email: VAMedicaidProviderEnrollment@gainwelltechnologies.com

Provider HELPLINE

Monday–Friday 8:00 a.m.-5:00 p.m. For provider use only, have Medicaid Provider ID Number available.

1-804-786-6273

1-800-552-8627