20-930 Give Timely Flu Shots to Help Keep Members Healthy
Date: 11/16/20
This information applies to Physicians and Participating Physician Groups (PPGs).
For Medi-Cal, this information applies to Kern, Los Angeles, Riverside, Sacramento, San Bernardino, San Diego, San Joaquin, Stanislaus, and Tulare counties.
Availability through providers, local health clinics or network pharmacies can help remove barriers to access the flu vaccine
The flu vaccine is critical to keeping the most vulnerable patients from having the flu and COVID-19 at the same time.
Encouraging the flu vaccine among members can also help conserve health care system resources during the COVID-19 crisis and reduce the prevalence of illness caused by the flu, thereby reducing outpatient visits or hospital admissions.
The flu vaccine is a covered benefit
As a reminder, Health Net and delegated at-risk participating physician groups (PPGs) must cover the flu vaccine for all members as an essential preventive services benefit. It is not subject to prior authorization, precertification or cost share.
As a preventive measure, providers are encouraged to offer members the flu vaccine during an appointment. If you do not have access to the vaccine, you can refer members to a local health department, health clinic, retail clinic or network pharmacy (dependent on the member’s policy or plan). Please inform member that out-of-pocket costs may apply if they receive the flu vaccine at these other locations.
You may use the VaccineFinder website as a resource to find a location close to a member’s home. Be sure to verify flu vaccine coverage for any location pursuant to the member’s policy or plan.
If you need help finding a participating provider for a member, please contact the appropriate Provider Services Center, as listed in the right-hand column.
Responsibilities of delegated entities
Delegated PPGs that have risk for the flu vaccine are required to cover the flu vaccine for members. Please also ensure:
- Members have timely access to the vaccine without the need for prior authorization, precertification or cost share.
- Members are referred to alternative sites for flu vaccine in the event the vaccine is not available through their provider or network
- Arrangements are made to avoid any out-of-pocket costs for members.
Delegated at-risk PPGs are required to cover the costs of the flu vaccine for members who may be referred to out an out-of-network provider or pharmacy during the COVID-19 state of emergency. Such flu vaccines paid by Health Net or paid out-of-pocket by the member will be deducted from the PPG’s next capitation payment, where applicable.
How to bill the vaccine
Providers can submit a claim for the flu vaccine itself and the administration of the vaccine to Health Net or your PPG. Reimbursement corresponds to the Division of Financial Responsibility between Health Net and the PPG, and is in accordance with the terms in your Health Net Provider Participation Agreement (PPA) or your contract with the PPG, as applicable.
If you are a Medi-Cal provider, the Vaccines for Children program provides free pediatric flu vaccines. However, you can bill the administration of the vaccine to Health Net or the PPG, as applicable.
Additional information
If you have questions regarding the information contained in this update, contact the applicable Health Net Provider Services Center within 60 days at:
Line of Business | Telephone Number | Provider Portal | Email Address |
|---|---|---|---|
EnhancedCare PPO (IFP) | 1-844-463-8188 |
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EnhancedCare PPO (SBG) | 1-844-463-8188 |
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Health Net Employer Group HMO, POS, HSP, PPO, & EPO | 1-800-641-7761 |
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IFP (CommunityCare HMO, PPO, PureCare HSP, PureCare One EPO) | 1-888-926-2164 |
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Medicare (individual) | 1-800-929-9224 |
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Medicare (employer group) | 1-800-929-9224 |
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Medi-Cal | 1-800-675-6110 |
| N/A |