Flu, RSV, and COVID-19 vaccine recommendations: Fall and winter 2023–2024

By December 15, 2023: Billing and clinical teams must review UPMC Health Plan vaccine coverage matrix and update internal guidelines to reflect fall/winter 2023-2024 recommendations. Specifically: (1) Verify all vaccine claims (flu, COVID-19, RSV) comply with CDC/ACIP age and dosing requirements before submission; (2) For RSV claims—confirm Abrysvo/Arexvy are billed only for adults 60+ using shared clinical decision-making documentation, and Beyfortus is billed only for infants <8 months (50mg if <5kg, 100mg if ≥5kg) or children 8-19 months at high risk (200mg); (3) For COVID-19 claims—verify updated vaccine formulations (Pfizer-BioNTech, Moderna, or Novavax) are used and appropriate dosing for age group and immunocompromised status; (4) Flag claims using out-of-network providers or non-ACIP-compliant administration for member cost-share application per plan design. Update billing software and/or encounter templates to include vaccine-specific age/indication fields. Contact UPMC Health Plan Member Services or check provider portal for participating pharmacy networks. Providers remain ultimately responsible for accurate and compliant billing submissions. Non-compliant claims will be denied or require member cost-share collection.