AAFP Query Prompts CMS Order on Pneumococcal Vaccine Denial

FPs Whose Claims Were Denied Should Resubmit for Payment

October 16, 2019 02:26 pm News Staff

Family physicians, if some of your Medicare claims for administering pneumococcal vaccinations have been denied, you may be able to take action to receive the payment you deserve.

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Here's why. A few months ago, the AAFP learned that some family physicians had experienced denials of these claims and asked CMS to investigate the matter.

On review, CMS discovered that some Medicare administrative contractors had implemented pneumococcal vaccination frequency edits that were inconsistent with national Medicare coverage rules.

Specifically, MACs had inserted lifetime limits as well as edits regarding time elapsed between vaccination. When administered vaccinations ran afoul of those restrictions, the claims were denied.

CMS issued instructions to all MACs on Sept. 13 directing them to halt any local frequency editing related to pneumococcal vaccinations within five business days -- or by Sept. 20.

The AAFP was informed that MACs would not automatically reprocess claims that were incorrectly denied; rather, physicians should resubmit those claims if the date of service falls within Medicare's timely filing limits -- defined as no later than 12 months or one calendar year after the date of service.

If services provided fall outside that time frame, physicians must request a reopening of denied claims.