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December 2016 Texas Medicaid Provider Procedures Manual

Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook : 9 Physician : 9.2 Services, Benefits, Limitations, and Prior Authorization : 9.2.36 Immunizations for Clients Birth through 20 Years of Age : 9.2.36.1 Vaccine Coverage Through the TVFC Program

9.2.36.1
Providers may refer to the TVFC web site at www.dshs.state.tx.us/immunize/tvfc/default.shtm for information about the program and for a list of vaccines available through the program.
Note:
TVFC program resolutions do not always match the ACIP’s general usage recommendations, but rather represent the rules that providers must follow when administering each specific vaccine under the TVFC.
When a single antigen vaccine or toxoid or a comparable antigen vaccine or toxoid is available through TVFC, but the provider chooses to use a different ACIP-recommended product, the administration fee will be reimbursed but the vaccine or toxoid will not be reimbursed.
Although Texas Medicaid does not mandate that providers enroll in TVFC, Texas Medicaid will not reimburse providers when the vaccine is available through TVFC. Only the administration fee will be reimbursed through Texas Medicaid when the vaccine or toxoid procedure code is identified on the claim. Clients may not be billed for vaccines and toxoids that are available through TVFC.
If a vaccine or toxoid meets the definition of “not available” through TVFC, it may be separately reimbursed through CCP when billed with modifier U1. Modifier U1 may be used in the following situations:
The TVFC, based on their federal resolution (distribution/guidelines), does not distribute an HHSC-approved vaccine or toxoid following the ACIP recommendation, and the provider purchases vaccine to administer to all ACIP-recommended ages or risk groups.
HHSC will notify providers if a vaccine or toxoid meets the definition of “not available” from TVFC and when the provider’s privately purchased vaccine or toxoid may be billed with modifier U1. Modifier U1 must not be used due to a provider’s failure to enroll in TVFC or to maintain sufficient TVFC vaccine or toxoid inventory.
Refer to:
Subsection 5.1.3, “Texas Vaccines for Children (TVFC) Program,” in the Children’s Services Handbook (Vol. 2, Provider Handbooks) for additional information about TVFC and immunizations for infants and children.

Texas Medicaid & Healthcare Partnership
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