Frequently Asked Questions

The WVA

Why is the WVA necessary?
Without the WVA, the state might not have continued universal purchase of childhood vaccines. Funds for state-supplied vaccines for privately insured children were scheduled to end on May 1, 2010. In response, the state legislature created the WVA to collect funds from health insurers and remit them to the state to cover the cost of vaccines for privately insured children. As a result, Washington continues to purchase vaccines for all children at volume rates and deliver them to providers at no charge. For more details, please see About Us.

Provider Requirements

How do the changes to state-supplied children’s vaccines affect my practice?
Because health plans, insurers, and other payers now pay for the cost of the vaccine supplied by the state and administered to children with private insurance, the billing process has changed for physicians, clinics, hospitals, and other providers. For each administered vaccine, you must now submit two forms to the appropriate health plan, insurance company, or TPA:

• The usual HCFA 1500 form for the administration of the vaccine, office visit, and other charges, just as you always have, but without the vaccine codes and modifiers. (The payer reimburses you for these costs.)
• A second HCFA 1500 form that contains the vaccine codes, the dosage-based assessment (DBA) charges, which you’ll find on the WVA Assessment Grid, and our tax ID number: 27-2251833. You may want to review the DBA Form Sample.

What if my system can’t handle the two-form DBA process?
Providers who have not yet changed to the two-form DBA process should contact the WVA for help (888-928-2224).

Where do I put the NPI number on the DBA form?
To be safe, we suggest putting the WVA NPI in both boxes 24J and 33A, and the provider's NPI in box 32A. (It also seems to be acceptable to put the provider's NPI in box 24J, and the WVA NPI in box 33A.)

How does the DBA process work with the electronic form?
If you already submit electronic forms, please feel free to continue doing so. Simply submit the DBA information to the appropriate payer using the payer's ID #. The information should also contain:

• CPT code for the state-supplied vaccine — without modifiers
• Vaccine assessment charge found on the WVA Assessment Grid.
• WVA tax ID: 27-2251833
• WVA mailing address:
  Washington Vaccine Association
  PO Box 94002
  Seattle, WA 98124-8402
• WVA's NPI #: 1699092718

We’re submitting the electronic form, but we can’t get the HCFA 1500 to include the WVA’s NPI in box 24J, while also keeping Box 31 (physician’s signature) blank. What should we do?
It is fine to populate Box 31. The WVA doesn’t need the physician’s signature which is why we say to leave it blank, but you can populate Box 31 in whatever way works for your system.

What codes and assessment charges are you asking for?
CPT codes and assessment charges for vaccines are available on the WVA Assessment Grid.

What if I decide not to participate?
According to the state statute that created the Washington Vaccine Association, payers can deny claims for privately purchased vaccines. As you make your decision, we encourage you to consider the benefits of the state’s universal purchase system in which vaccines are purchased at federal contract rates.

• You continue to receive vaccines at no charge, while giving your patients easy access to critical vaccinations.
• You avoid the financial and staffing burden required to purchase vaccines on your own.
• You don’t need to store vaccines separately for privately and federally covered children.

Can we refer insured children some place else if we decide to only handle children without insurance?
Not really. Community clinics lack sufficient resources to absorb insured patients into their immunization services. Furthermore, referring children out increases the potential of their not being vaccinated at all.

Who will pay the cost of changing our billing process for state-supplied vaccines?
Unfortunately, there are no special funds to cover these expenses, which is why we’ve tried to make the changes as easy as possible. We’re here to help in any way we can. Simply contact us at info@wavaccine.org or 1-888-928-2242.

Do you have sample forms I can look at?
Yes. Here are the forms and charts that can help you:

DBA Form Sample (pdf)
Completed samples of the two forms required for the dosage-based assessment (DBA) process.
Electronic Form (Excel)
Spreadsheet that shows the fields and data for the electronic form format.
Washington Vaccine Association Assessment Grid
Chart listing the dosage-based assessment charges for vaccines covered by the state’s Childhood Vaccine Program.

DBA Methodology

How did you come up with the dosage-based assessment (DBA) methodology?
In the months leading up to the formation of the WVA by the state legislature, a multidisciplinary group of stakeholders evaluated a number of different methods based on how well they addressed the concerns of providers, payers, the state Department of Health, and the Centers for Disease Control.

The DBA methodology was the only one that could:

• Replicate processes that providers and payers already had in place, and
• Capture payments from out-of-state payers on May 1, 2010, the day state funds were scheduled to end and the WVA took over collecting and remitting funds to cover vaccines for privately insured children.

Once the DBA methodology was chosen, six health plans pre-paid $7.8 million to continue the funding for vaccines for privately insured children without interruption. By April 2011, the WVA had paid back the full amount.

Why can't the state Department of Health just give the shots to patients and get reimbursed by insurers, removing physicians altogether?
About 90 percent of childhood vaccinations are administered by private practice physicians. The state Department of Health does not have the infrastructure, resources, or budget to vaccinate this volume of children over the course of their lives. Furthermore, it’s far more convenient for most children to receive vaccinations from their own primary care services.

Federally Funded Vaccines for Children

Has anything changed for the federally funded Vaccines for Children (VFC)?
Neither the federally funded Vaccines for Children entitlement, nor the state’s purchase of vaccines for children in state-sponsored medical plans, were affected by budget cuts. Vaccines for these groups represent around two-thirds of the state’s vaccine budget.

Do providers need to screen for VFC eligibility?
Yes. VFC status screening is still a federal requirement for every visit and hasn’t changed. More information about VFC status screening, including frequently asked questions, is available at: www.doh.wa.gov/cfh/Immunize/vaccine/vfcstatus.htm.

Do providers need to put vaccines for privately insured children in a different refrigerator from federally funded vaccines?
No, you don’t need to separate your vaccines. This is one of the benefits of maintaining the universal purchase system.

Insurance Coverage

Is the HPV vaccine available under these new requirements?
Yes. The HPV vaccine was reinstated for all children under age 19 on May 1, 2010.

What about childhood vaccines that aren’t listed on the WVA Assessment Grid?
The assessment grid now includes all the childhood vaccines recommended by the federal Advisory Committee on Immunization Practices (ACIP). Other vaccines not included in the DBA process may be available from the state Department of Health under the Childhood Vaccine Program. For a complete list of all vaccines available through the Childhood Vaccine Program, please visit the state Department of Health's web site.

Can we bill for the flu vaccine?
Yes, the flu vaccine was added to the WVA Assessment Grid for the 2011-2012 flu season. Please refer to the grid for the billing amount.

What about Idaho residents who have vaccines administered by Washington providers?
Both the Idaho and Washington state departments of health have agreed that providers should be able to administer state-supplied vaccines without worrying about the residency of their patients. The two departments simply ask that you use your own state’s protocol in processing forms for administered vaccines.

As always, children who are eligible for vaccines under the federally funded Vaccines for Children program can continue to receive those vaccines at no cost to Washington practices.

Are the Hepatitis B and MMR vaccine exceptions still be in place?
Yes. Currently there are two exceptions to the age 19 limit — Hep B (for high risk groups up to their 20th birthday) and MMR (for college students born after 1957). As a result, these vaccines do not fall under our dosage-based assessment process when they're administered to patients age 19 or older. Otherwise, Hep B and MMR vaccines are part of the DBA process.

What if a child has no insurance?
Uninsured patients are eligible for vaccines at no charge through the Washington State Childhood Vaccine Program. For details about underinsured and uninsured children, please visit the Department of Health’s status screening frequently asked questions.

What if a privately insured child has run out of benefits and the insurer won’t cover vaccines?
The child may qualify as “underinsured” and therefore be eligible for vaccines at no charge through the state’s Childhood Vaccine Program. For details about underinsured and uninsured children, please visit the Department of Health’s status screening frequently asked questions.

What if a child’s preventive care benefit has run out?
Depending on the insurance plan, preventive care benefits may be subject to a co-pay, deductible, and/or limit on the maximum preventive care coverage per year. Before doing anything else, parents should verify the terms of their preventive care benefit by calling their health plan.

If in fact the child has exceeded the maximum benefit amount, the child may qualify as “underinsured” through the federally funded Vaccines for Children (VFC) program, making the child eligible for vaccination under VFC.

In any case, it’s important to know that the WVA will never collect vaccine charges from parents. If the insurance company denies coverage because of a remaining deductible or maxed-out benefit, WVA will not bill parents for the cost of the administered vaccine.

In addition, since providers receive state-supplied vaccines at no charge, they should never bill the parents for a vaccine administered to a child under 19. (They should, however, process the dosage-based assessment (DBA) forms.)

Finally, under the new federal health care legislation, insurers can no longer impose a maximum amount on preventive care benefits, beginning with the renewal date of the child's or family policy.

What if we don't know if the patient's plan covers vaccines?
Even if you don’t know the terms of the health plan, you should process the vaccine assessment and office charges using the insurance information available. If the patient does not have vaccine coverage, the health plan will determine how to manage the assessment.

In general, health plans adjudicate claims based on your submission. A single form generates a single explanation of benefits (EOB); the two-form DBA process generates two EOBs (one for the provider, one for the WVA).

Should we bill all private insurance payers, regardless of coverage?
Yes.

Do out-of-state payers know about the DBA billing process?
To date, all major out-of-state plans are reimbursing providers using the DBA methodology.

In general, the DBA methodology was created to help ensure that out-of-state insurers paid their fair share of the assessment charges for vaccines administered to in-state children. Without this methodology, or some other viable means of billing out-of-state payers, vaccines would have to be subsidized by in-state insurers and their health plan members.

If a payer denies the charges on a DBA submission, do we bill the payer again?
No. First, the WVA receives the explanation of payments made, not the providers who administered the vaccine. If payment is denied because, for example, the member’s insurance doesn’t include a preventive care benefit, or the payer billed wasn’t the member’s primary insurer, you don’t have to bill again. Second, such payment denials are considered “leakage,” though we are monitoring leakage to determine how to minimize it.

Does this change the way we document a patient's chart for our electronic medical records (EMR), or is it only a billing change?
This is only a billing change.

We bill through a clearinghouse. What if a claim scrubber rejects our submissions because we used your federal tax ID and NPI numbers?
Please advise your clearinghouse that you’ll be using the DBA process, with our name, Tax ID, and NPI. If you run into problems, contact us at info@wavaccine.org.

Does billing insurers under the WVA tax ID # create a de facto relationship between you and my practice, making my practice accountable to you for the accuracy and timeliness of our billing?
No. It is the responsibility of health plans to monitor their systems to make sure they received DBA forms from the WVA that correspond to vaccine administration claims from providers’ offices. That said, inaccurate or untimely billings only undermine the WVA’s ability to transmit funds for state-supplied vaccines to privately insured children.

Is the vaccine administration fee still $15.60, or is that up to the payer?
For privately insured children, you are not limited to the CMS (Centers for Medicare and Medicaid Services) regional cap of $15.60. As long as your practice conducts Vaccines for Children (VFC) status screenings, you can bill payers for administration fees that are usual and customary for your practice.

What will payers like Molina do where the vaccine is the primary charge, not the administration fee?
Department of Health and Human Services plans do not require the DBA billing process — dosage-based assessments apply only to private health insurance.

Do I use the DBA process for billing when a patient has primary insurance from a private insurer and secondary insurance from the state?
If you normally bill the state insurance plan or the Department of Social and Health Services (DSHS) for the vaccine, continue to do so. If you normally bill the private insurance carrier, use the DBA process.

How does this affect Medicaid and Medicaid managed-care plans?
There should be no change in the way you bill or work with Medicaid and Medicaid managed-care plans for children covered by those plans.

Do providers need to continue filling out the vaccine reports for Public Health, in addition to completing the new tracking reports?
Yes. For now, the current program requirements stay the same.

What kind of auditing process can we expect?
Health plans monitor their own claim systems to make sure they receive DBA forms from the WVA that correspond to vaccine administration claims from providers.

How are the vaccines reported for patients who don't have insurance?
DBA forms are not required for uninsured children. Bill those patients for services as you usually do, providing vaccines at no cost through the federally funded Childhood Vaccine Program and reporting those vaccines to your local health jurisdiction.

Will providers receive notification when WVA receives payments from insurers? If we don’t, my billing system will show unpaid claims.
No, you won’t receive notification, but the DBA shouldn’t show up as accounts receivable in your system. Nor are you responsible for making sure that the WVA receives payment for the vaccines you administer and document through the DBA process.

Whose responsibility is it to make sure the DBA information reaches the payer and that payment reaches the WVA?
It is the provider's responsibility to complete the DBA process accurately to avoid denials. Once the forms reach the payer, it is the payer's responsibility to send payment to the WVA.

Do we still need to report vaccine usage by age group, or will the WVA gather that data?
Reporting vaccines by age group is a federal requirement for the state Department of Health’s Childhood Vaccine Program, so you need to continue providing the data. The reports capture data for vaccines administered to all children, not just those with insurance.

Are the requirements for providers compliant with HIPAA requirements?
Yes.

Don’t we have to have an agreement with you in accordance with HIPAA laws, since you receive patient information?
As a business partner, the WVA must comply with HIPAA regulations.

Can patients who want to keep their vaccinations confidential (e.g, for HPV) opt out of having the insurer billed so their parents don’t find out?
All health plans are required to follow HIPAA guidelines when sending sensitive materials to members. You may want to advise patients to contact their health plans to find out what measures can be taken to protect their privacy in such situations.