MedicaidCoverageMedium impact
Newsletter Vol. 3, No. 50
New Jersey Medicaid·NJ · Pharmacy, Geriatrics, Infectious Disease·Provider Notice
We identified it
Jun 20, 2026
Summary
This policy clarifies influenza immunization coverage and billing procedures for Medicaid recipients in long-term care settings. Key updates: (1) Physicians cannot bill for vaccine administration when facility staff administers it; (2) For dually eligible Medicare/Medicaid recipients, the Medicare intermediary must be billed for the influenza vaccine, not Medicaid.
Action Required
Immediately: Billing team must implement the following protocol for influenza vaccine claims: (1) Do NOT bill for vaccine administration when ordered by physician but administered by nursing facility or institutional staff; (2) For dually eligible Medicare/Medicaid patients, route influenza vaccine claims to the Medicare intermediary only—do not submit to Medicaid. (3) Contact the Pharmaceutical Consultant in the Medicaid District Office if procedures for obtaining and billing vaccines in long-term care settings are unclear. Failure to route claims correctly will result in denials and compliance issues.