016.06.06 Ark. Code R. 053
The child's immunization status should be assessed from the child's health record. If the child needs any immunization at the time of the screening, the immunization(s) will be administered as part of the screening process.
Immunizations for childhood diseases are exempt from primary care physician (PCP) referral requirements.
The Arkansas Medicaid program recommends that EPSDT providers follow the immunization schedule shown in the attached chart established by the Advisory Committee on Immunization Practices (ACIP), the American Academy of Pediatrics (AAP) and the American Academy of Family Physicians (AAFP).
The current immunization schedule indicates the recommended ages for routine administration of currently licensed childhood vaccines, as of December 1, 2005, for children through age 18 years. Providers may access the original chart at www.cdc.gov/nip/acipand follow the links to "childhood immunizations."
The Vaccines for Children (VFC) Program was established to generate awareness and access for childhood immunizations. To enroll in the VFC Program, contact the Arkansas Division of Health. Providers may also obtain the vaccines to administer from the Arkansas Division of Health. View or print Arkansas Division of Health contact information.
Vaccines available through the VFC program are covered for Medicaid-eligible children. Only the administrative fee is reimbursed. When filing claims for administering VFC vaccines,
providers must use the CPT procedure code for the vaccine administered. Electronic and paper claims require modifiers EP and TJ. When filing paper claims, type of service code "6" and the modifiers EP and TJ must be entered on form DMS-694. View or print a DMS-694 sample claim form.
Medicaid policy regarding immunizations for adults remains unchanged by the VFC program.
Providers may consult the Physician's manual to view the list of vaccines that are non-VFC but are covered for beneficiaries who are 19 and 20 years of age. The following list contains the vaccines available through the VFC program.
* Effective for dates of service on and after March 1, 2006 ** Effective for dates of service on and after July 10, 2006
Procedure Code | M1 | M2 | Age Range | Vaccine Description |
90633* | EP | TJ | 12 months-18 years | Hepatitis A vaccine, pediatric/adolescent dosage-2 dose schedule, for intramuscular use |
90634* | EP | TJ | 12 months-18 years | Hepatitis A vaccine, pediatric/adolescent dosage-3 dose schedule, for intramuscular use |
90636 | EP | TJ | 18 years only | Hepatitis A and hepatitis B vaccine (HepA-HepB), adult dosage, for intramuscular use |
90645 | EP | TJ | 0-18 years | Hemophilus influenza b (Hib) HbOC conjugate (4 dose schedule) for intramuscular use |
90646 | EP | TJ | 0-18 years | Hemophilus influenza b (Hib) PRP-D conjugate for booster use only, intramuscular use |
90647 | EP | TJ | 0-18 years | Hemophilus influenza b (Hib) PRP-OMP conjugate (3 dose schedule), for intramuscular use |
90648 | EP | TJ | 0-18 years | Hemophilus influenza b vaccine (Hib), PRP-T conjugate (4 dose schedule), for intramuscular use |
90655 | EP | TJ | 6 months-35 months | Influenza virus vaccine, split virus, preservative free, for children 6-35 months of age, for intramuscular use |
90656 | EP | TJ | 3 years-18 years | Influenza virus vaccine, split virus, preservative free, for use in individuals 3 years and above, for intramuscular use |
90657 | EP | TJ | 6 months-35 moths | Influenza virus vaccine, split virus, for children 6-35 months of age, for intramuscular use |
90658 | EP | TJ | 3 years-18 years | Influenza virus vaccine, split virus, for use in individuals 3 years and above, for intramuscular use |
90660 | EP | TJ | 5 years-18 years (not pregnant) | Influenza virus vaccine, live, for intranasal use |
90669 | EP | TJ | 0-4 years | Pneumococcal conjugate vaccine polyvalent, for children under 5 years, for intramuscular use |
90680** | EP | TJ | 6 weeks to 32 weeks | Rotavirus vaccine, pentavalent, 3 dose schedule, live, for oral use |
90700 | EP | TJ | 0-6 years | Diphtheria, tetanus toxoids and acellular pertussis vaccine (DTaP), for use in individuals younger than 7 years, for intramuscular use |
90707 | EP | TJ | 0-18 years | Measles, mumps and rubella virus vaccine (MMR), live, for subcutaneous use |
90710* | EP | TJ | 0-18 years | Measles, mumps, rubella, and Varicella vaccine (MMRV), live, for subcutaneous use |
90713 | EP | TJ | 0-18 years | Poliovirus vaccine, inactivated (IPV), for subcutaneous or intramuscular use |
90714 | EP | TJ | 7-18 years | Tetanus and diphtheria toxoids (Td) adsorbed, preservative free, for use in individuals 7 years or older, for intramuscular use |
90715* | EP | TJ | 7-18 years | Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap), for use in individuals 7 years or older, for intramuscular use |
90716 | EP | TJ | 0-18 years | Varicella virus vaccine, live, for subcutaneous use |
90718 | EP | TJ | 7-18 years | Tetanus and diphtheria toxoids (Td) absorbed for use in individuals 7 years or older, for intramuscular use |
90721 | EP | TJ | 0-18 years | Diphtheria, tetanus toxoids and acellular pertussis vaccine and Hemophilus influenza B vaccine (DtaP-Hib), for intramuscular use |
90723 | EP | TJ | 0-18 years | Diphtheria, tetanus toxoids and acellular pertussis vaccine, Hepatitis B, and poliovirus vaccine, inactivated (DTaP-HepB-IPV)( for intramuscular use |
90734* | EP | TJ | 0-18 years | Meningococcal conjugate vaccine, serogroups A, C, Y and W-135 (tetravalent), for intramuscular use |
90743 | EP | TJ | 0-18 years | Hepatitis B vaccine, adolescent (2 dose schedule), for intramuscular use |
90744 | EP | TJ | 0-18 years | Hepatitis B vaccine, pediatric/adolescent (3 dose schedule), for intramuscular use |
90747 | EP | TJ | 0-18 years | Hepatitis B vaccine, dialysis or immunosuppressed patient dosage (4 dose schedule), for intramuscular use |
90748 | EP | TJ | 0-18 years | Hepatitis B and Hemophilus influenza b vaccine (HepB-Hib), for intramuscular use |
016.06.06 Ark. Code R. 053