UMR revised its preventive vaccine (immunization) coverage criteria so that a vaccine is covered as a preventive care service when it is subject to explicit recommendations (should, shall, is) from the American Academy of Family Physicians, American Academy of Pediatrics, or American College of Obstetricians and Gynecologists, and the earlier requirement that recommendations not be permissive ('may') was removed. The FDA-approval and plan-exclusion conditions still apply, and the policy adds a reference to the applicable vaccine codes list (CPT 90616, 90657, 90658). Billing staff should review vaccine claims for these plans to confirm the codes and recommendation basis they submit align with the updated criteria.
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01By 2026-12-01: Billing team should review vaccine claims for UMR members (CPT 90616, 90657, 90658 and related immunization codes) and confirm that the vaccine billed is FDA-approved and not excluded under the member's plan.
02Update the preventive vaccine code list used in charge entry so that vaccines with explicit (non-permissive) recommendations from AAFP, AAP, or ACOG are billed under preventive benefits, and route vaccines recommended only with permissive language or outside these organizations to providers for review of whether a therapeutic or other benefit applies.
03Tell providers and front desk staff about the revised criteria so vaccine orders and visit documentation reflect the recommending organization.
Codes mentioned
906169065790658
Original notice
Preventive Vaccines (Immunizations)
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