Question Florida Medicaid/Medikids Vaccine Reimbursement


Homosassa, FL
Best answers
Hello, I don't actually do the billing for my office but I work with the billers and we are having an issue with reimbursement on some of our vaccines. I know children on full medicaid program receive VFC vaccines and we do not get reimbursed for that but we can be reimbursed for 90460. For the children that are on Medikids, they do not qualify for VFC per VFC eligibility guidelines. I have some health plans that are not reimbursing us for those vaccines and we have done appeals, opened cases and now have an open AHCA complaint and they're still arguing this with me. One health plan said today the issue is we are billing the preventative office visit code with the vaccine and admin codes and they should be on separate claim forms. When the patient is on regular medicaid with that health plan, they pay for OV and admin fee, but when they're on Medikids they're claiming they wont pay for 90460 with the preventative visit. But, when we have a child come in for a flu vaccine only, they still don't pay for the 90460 with a flu vaccine only so that contradicts their statement in my opinion.

Is anyone familiar with Medikids and having "medicaid" patients that do not qualify for VFC vaccines and have an issue being reimbursed for the admin fee and/or vaccine? We verify the patient's eligibility for VFC vaccines prior to the office visit and if their benefit plan states MK:A, MK:B or MK:C they are ineligible for the VFC program and they're required to receive vaccines from our private stock and we are supposed to receive payment from the SMMC plan.

Hopefully someone else has experienced this and can give insight on how they resolved it. I've in contact with Pharmacy Policy Department at AHCA and they're the ones that make the fee schedules for immunizations and they have confirmed I am indeed correct and should file the complaint, but I am still not getting anywhere. Any help is greatly appreciated!