Respiratory Syncytial Virus (RSV) Vaccines for Adult and Maternal Use (CPB 1027, reviewed 2025-10-09)

Immediately: Billing team must configure system to recognize and process RSV vaccine claims using CPT codes 90678, 90679, 90683, and HCPCS code 90382 when accompanied by appropriate ICD-10 codes (Z29.11 for ages 50-75 with risk factors or 75+; Z3A.32-Z3A.36 for pregnant members 32-36 weeks gestation). Update claim submission logic to: (1) Accept administration codes 96380 and 96381 for vaccine administration; (2) Require documentation of age verification (75+) or risk factor criteria (age 50-74) or gestational age (32-36 weeks) before claim approval; (3) Restrict Abrysvo seasonal administration to September-January unless member is in non-continental US jurisdiction; (4) Block coverage for members under 60 without documented risk factors, members outside 32-36 week gestational window, and any revaccination attempts. Update prior authorization workflows to reference the Risk Factor Appendix mentioned in the policy. Providers and front-desk staff must collect qualifying criteria documentation at point-of-service. Claims submitted without proper age/risk documentation or outside covered criteria will be denied.