FAQs

All major out-of-state plans are participating in the assessment process by using the DBA methodology. One of the benefits of the DBA methodology is to ensure that out-of-state insurers pay their fair share of the assessment charges for vaccines obtained via the DOH CVP program administered in Washington.

No. The WVA collects funds from private insurers and remits monies to the Department of Health to replenish their vaccine supply funding within their Childhood Vaccine Program (CVP).

The assessment grid now includes all the childhood vaccines routinely recommended by the federal Advisory Committee on Immunization Practices (CIP). Other vaccines not included in the DBA process may be available from the state department of health under the Childhood Vaccine Program. For a complete list of all vaccines available through the Childhood Vaccine Program, please click here.  The assessment grid should be reviewed for vaccines that have been offered on past grids, as providers may administer still viable “left-over” vaccine material that was on an earlier grid.

The Program assesses payers at rates that are lower than reimbursing the costs of private purchase of vaccines. In addition, payers are funding vaccines equitably and in proportion to their enrolled membership.

The new pricing grid for WVA vaccine material is updated each July 1, and runs through June 30 of the following year.  This requires updating of “fee schedules” for both providers and payers to ensure the WVA receives proper payment.

The WVA updates the WVA Assessment Grid annually, following CDC rate changes effective April 1. If unique situations arise, the WVA Assessment Grid may be reviewed and update more often than annually.

Pursuant to RCW 70.290.075, if the clients represented by the TPA offer private health plan or self-funded employer plan coverage that might include vaccine material being provided to patients under the age of 19, then both state-based and out-of-state TPAs are required to register with the Washington Vaccine Association so we can keep you informed of the latest policies, changes, and reductions to vaccine charges. You only need to register once as long as your information is current. Your record can be modified by going to the registration page and entering your EIN and password.

It is the provider’s responsibility to complete the DBA process accurately to avoid denials. Once the forms reach the payer, it is the payer’s responsibility to send payment to the WVA.

It is the provider’s responsibility to complete the DBA process accurately to avoid denials and to resubmit or respond to payer requests to the same extent as the administration claim. Once the forms reach the payer, it is the payer’s responsibility to send the assessment to the WVA.

The COVID-19 vaccine commercialization went into effect September 14, 2023. For information please use the WVA COVID-19 page at this link:

COVID-19 | Washington Vaccine Association (wavaccine.org)

No.  The patient should be considered uninsured and vaccine material billed accordingly, outside of the WVA, DBA process.

Health care sharing plans are not regulated by the Washington State Office of the Insurance Commissioner and therefore are not considered health insurance nor are they required to remit DBA payments. Providers should be processing them as uninsured patients according to the Department of Health (DOH) policy statement found at this link.

Generally, vaccines will be added when the following information is available: FDA approval, coding availability, vaccine availability, and pricing information.

You can check what has been entered by entering your EIN and password on the registration page and the current entry will be displayed.

First, you will want to make sure that the vaccine material is listed on the Vaccine Assessment Grid (see the Assessment Grid and tips page on our website) as some vaccine material offered through the Washington DOH CVP is not on the Vaccine Assessment grid.

Second, you will want to ensure the patient’s health coverage is private or commercial insurance, or a self-funded employer group plan.  If it is then refer to the DOH Eligibility for Publicly Funded Vaccines: A Guide for Providers to determine if the circumstances require a DBA or other form of claim.

The WVA is defined as a Public Health & Welfare agency under the provider identification and billing taxonomy code 251K00000X. Washington State’s universal vaccine program requires payer payment to the WVA regardless of contractual status between the payer and the provider. Additionally, the WVA is not required to be in network with the payer. This means that a provider will bill the payer via the DBA process with the WVA as the pay-to billable provider.

It is highly possible that payer adjudication systems will filter out and reject non-network providers, whether rendering, or billable, on the DBA submission. Providers can assist in the DBA submission process by reviewing the following WVA Private Insurance Assessment Billing Provider & Payer Guide (pgs. 3 & 4) for vaccine material assessment and adding a notation on DBA claims as follows: for paper billing, in Box 19 “WVA does not need to be in network for grid payment”, or electronically the same phrase in loop 2300, seg./element NTE01, qualifier Add.

It will also assist the payer to process the DBA correctly if providers be sure to include the WVA taxonomy code (251K00000X) as follows:  for paper billing, in Box 33b, or electronically in loop 2000a, seg./element PRV02, qualifier PXC.

To be proactive, the WVA suggests the provider reach out to their payer representative(s) to confirm they are prepared to recognize and process the DBAs correctly.

Out-of-state payers may engage in our program as out-of-state covered lives under age 19 who are vaccinated by a State of Washington provider in Washington with material via the DOH CVP program that is on the WVA grid can receive the material at no cost via the DBA claim process.

If there is private health plan coverage for the vaccine, it doesn’t matter if it’s an out-of-state patient who gets the vaccine.  A DBA from the provider is submitted to the payer, who in turn issues payment to the WVA.  The WVA in turn helps to “fund” the DOH CVP pool for the material.

The physical address for the WVA is an administrative address which should not be used as our pay-to address or for any form of communication. Electronic submissions require use of PO Box 94002, Seattle, WA  98124-9402, including  Loop 2010AB.  The physical address is required on your electronic medical records (EMR) system when submitting DBAs electronically in Loop 2010AA.  The current physical address is: 1700 Seventh Ave., Suite 1810, Seattle, WA  98101 (formerly Marketplace Tower PH-A, 2025 First Ave, Seattle, WA).

The assessment grid contains the per dose assessment rate remitted by payers to the WVA. The grid contains the CPT code, NDC code, and vaccine trade name in addition to the assessment rate. Beginning with the 2020-21 grid, it includes a listing of prior discontinued NDC and CPT codes at the end of the document for legacy referencing.

The grid is updated annually and is in effect from July 1 – June 30.  It is expected that providers will submit a dosage-based assessment (DBA) to the patient’s private insurance carrier or third-party administrator in the amount found on the grid, and that the carrier will remit that amount to the WVA.

To ensure proper DBA submission and carrier/TPA remittance to the WVA, please check the:

• Date of service to ensure the correct grid is being used;
• CPT code to ensure it is a valid code (*see note below); and
• Assessment amount to ensure proper DBA submission and carrier/TPA remittance to the WVA.

*Please note:  Sometimes rendering providers can obtain vaccine material that is still viable and can administer it, even if it has been discontinued from prior grids and not showing on the current grid. If the CPT code is not offered on the current grid, providers should check the legacy information at the end of the grid document, and if a code was offered on a past WVA grid the last published assessment amount is what should be remitted to the WVA.

There are many benefits of the state’s universal purchase system:

Providers, at no charge, continue to receive vaccines for all of their private health plan patients less than 19 years of age, which provides patients easy access to critical material at no cost.

• Providers avoid the financial, storage, and staffing burden required to purchase vaccines on their own
• Providers are not required to store vaccines separately for privately and federally covered

If you need help billing the Dosage-Based Assessment (DBA), please contact us at info@wavaccine.org or 1-888-928-2224. Finally, according to the state statute that created the Washington Vaccine Association, payers can deny claims for privately purchased vaccines.

No. As a business partner, the WVA must comply with HIPAA regulations and you do not need a Business Associates Agreement with the WVA.

No. The WVA collects funds from private insurers and remits monies to the Department of Health to replenish their vaccine supply funding within their Childhood Vaccine Program (CVP).

No, you do not need to separate your vaccines. This is one of the benefits of maintaining the universal purchase system.

First, you will want to make sure that the vaccine material is listed on the Vaccine Assessment Grid (see the Assessment Grid and tips page on our website) as some vaccine material offered through the Washington DOH CVP is not on the Vaccine Assessment grid.

Second, you will want to ensure the patient’s health coverage is private or commercial insurance, or a self-funded employer group plan.  If it is then refer to the DOH Eligibility for Publicly Funded Vaccines: A Guide for Providers to determine if the circumstances require a DBA or other form of claim.

No.  The patient should be considered uninsured and vaccine material billed accordingly, outside of the WVA, DBA process.

Health care sharing plans are not regulated by the Washington State Office of the Insurance Commissioner and therefore are not considered health insurance nor are they required to remit DBA payments. Providers should be processing them as uninsured patients according to the Department of Health (DOH) policy statement found at this link.

The WVA is defined as a Public Health & Welfare agency under the provider identification and billing taxonomy code 251K00000X. Washington State’s universal vaccine program requires payer payment to the WVA regardless of contractual status between the payer and the provider. Additionally, the WVA is not required to be in network with the payer. This means that a provider will bill the payer via the DBA process with the WVA as the pay-to billable provider.

It is highly possible that payer adjudication systems will filter out and reject non-network providers, whether rendering, or billable, on the DBA submission. Providers can assist in the DBA submission process by reviewing the following WVA Private Insurance Assessment Billing Provider & Payer Guide (pgs. 3 & 4) for vaccine material assessment and adding a notation on DBA claims as follows: for paper billing, in Box 19 “WVA does not need to be in network for grid payment”, or electronically the same phrase in loop 2300, seg./element NTE01, qualifier Add.

It will also assist the payer to process the DBA correctly if providers be sure to include the WVA taxonomy code (251K00000X) as follows:  for paper billing, in Box 33b, or electronically in loop 2000a, seg./element PRV02, qualifier PXC.

To be proactive, the WVA suggests the provider reach out to their payer representative(s) to confirm they are prepared to recognize and process the DBAs correctly.

Yes.  In the spring of 2020, changes were made to improve the DBA process to decrease errors and confusion at both the provider and payer levels.  While this may require changes in your workflows and electronic practice management systems, your efforts to participate and comply with the program ensure that Washington’s children receive vaccinations.

NPI Number Placement (the WVA NPI # is:  1699092718)

Taxonomy Codes (the WVA Taxonomy # is:  251K00000X)

Phone Number on the DBA (the WVA Phone # is:  888-928-2224)

It is the provider’s responsibility to complete the DBA process accurately to avoid denials and to resubmit or respond to payer requests to the same extent as the administration claim. Once the forms reach the payer, it is the payer’s responsibility to send the assessment to the WVA.

The majority of payers will send claim issues notices and remittances to the DBA billing provider which is: Washington Vaccine Association, PO Box 94002, Seattle, WA 98124-9402.  As a provider, you will have entered your rendering/treating provider’s billing office phone number in Box 33 on paper HCFA DBAs or Loop 2000A on electronic DBA submissions. This will enable payers to contact your office by phone if more information, or a corrected DBA is required by the payer.

Additionally, any claim processing issues a payer might have with the DBA will also apply to the separate, traditional administration/office claim that was created on the date of service when the DBA for the vaccine material itself was created.  If you discover and correct an issue with the administration/office claim to ensure your payment, you will need to do the same to resubmit the DBA.

No, you will not receive notification, but the DBA should not show up as accounts receivable in your practice management system. You are not responsible for ensuring that the WVA receives assessments for the vaccines you administer and document through the DBA process.  However, please see the Dosage-Based Assessment Billing section for guidance on provider DBA follow-up.

In 2007, a bill was passed by the Washington State Legislature that created the DCP designation. The bill required the Office of the Insurance Commissioner (OIC) to report annually to the Legislature on direct health care practices. The legislation did not contemplate the need to participate in the WVA’s assessment process, as the WVA had not yet been created.

DCPs currently order and receive vaccine supply from the Washington State Department of Health’s (DOH) Universal Childhood Vaccine Program (CVP), however, the DCPs do not currently reimburse the State for the vaccine used by their commercially insured and self-funded employer group patients less than 19 years of age.

A formal policy regarding how DCPs will participate with the WVA will be developed. Meanwhile, any questions from DCPs about the current vaccine programs can be directed to the Washington State DOH’s CVP at 1-866-397-0337 or WAChildhoodVaccines@doh.wa.gov.

Yes, providers now have the opportunity to change brands two times a year through the DOH online vaccine selection process.

Out-of-state payers may engage in our program as out-of-state covered lives under age 19 who are vaccinated by a State of Washington provider in Washington with material via the DOH CVP program that is on the WVA grid can receive the material at no cost via the DBA claim process.

If there is private health plan coverage for the vaccine, it doesn’t matter if it’s an out-of-state patient who gets the vaccine.  A DBA from the provider is submitted to the payer, who in turn issues payment to the WVA.  The WVA in turn helps to “fund” the DOH CVP pool for the material.

Both the Idaho and Washington state departments of health have agreed that providers should be able to administer state-supplied vaccines without worrying about the residency of their patients. The two departments simply ask that you use your own state’s protocol for administered vaccines.

The physical address for the WVA is an administrative address which should not be used as our pay-to address or for any form of communication. Electronic submissions require use of PO Box 94002, Seattle, WA  98124-9402, including  Loop 2010AB.  The physical address is required on your electronic medical records (EMR) system when submitting DBAs electronically in Loop 2010AA.  The current physical address is: 1700 Seventh Ave., Suite 1810, Seattle, WA  98101 (formerly Marketplace Tower PH-A, 2025 First Ave, Seattle, WA).

The COVID-19 vaccine commercialization went into effect September 14, 2023. For information please use the WVA COVID-19 page at this link:

COVID-19 | Washington Vaccine Association (wavaccine.org)

Generally, vaccines will be added when the following information is available: FDA approval, coding availability, vaccine availability, and pricing information.

The new pricing grid for WVA vaccine material is updated each July 1, and runs through June 30 of the following year.  This requires updating of “fee schedules” for both providers and payers to ensure the WVA receives proper payment.

The WVA updates the WVA Assessment Grid annually, following CDC rate changes effective April 1. If unique situations arise, the WVA Assessment Grid may be reviewed and update more often than annually.

The assessment grid now includes all the childhood vaccines routinely recommended by the federal Advisory Committee on Immunization Practices (CIP). Other vaccines not included in the DBA process may be available from the state department of health under the Childhood Vaccine Program. For a complete list of all vaccines available through the Childhood Vaccine Program, please click here.  The assessment grid should be reviewed for vaccines that have been offered on past grids, as providers may administer still viable “left-over” vaccine material that was on an earlier grid.

Yes. VFC status screening is still a federal requirement for every visit and has not changed. More information about VFC status screening, including frequently asked questions, is available here. Also, providers will be screening to determine what type of health plan coverage, or not, is presented by the patient and reviewing that against the DOH Eligibility Grid to determine how the vaccine should be billed.  The WVA area is private health coverage, and the method of presenting it to the payer is the DBA, Dosage Based Assessment.

Health plans monitor their own claim systems to make sure they receive DBA forms that correspond to vaccine administration claims from providers.

Yes. Providers must meet all requirements of the Childhood Vaccine Program and continue to submit accountability reports according to their Provider Agreement.

Reporting vaccines by age group is a federal requirement for the state Department of Health’s Childhood Vaccine Program, so you need to continue providing the data to them as required. The reports capture data for vaccines administered to all children, not just those with insurance.

In the months leading up to the formation of the WVA by the state legislature, a multidisciplinary group of stakeholders evaluated a number of different methods based on how well they addressed the concerns of providers, payers, the state Department of Health, and the Centers for Disease Control (CDC). The DBA methodology was the only one that could:

• Replicate processes that providers and payers already had in place, and
• Capture assessments from out-of-state

First, you will want to make sure that the vaccine material is listed on the Vaccine Assessment Grid (see the Assessment Grid and tips page on our website) as some vaccine material offered through the Washington DOH CVP is not on the Vaccine Assessment grid.

Second, you will want to ensure the patient’s health coverage is private or commercial insurance, or a self-funded employer group plan.  If it is then refer to the DOH Eligibility for Publicly Funded Vaccines: A Guide for Providers to determine if the circumstances require a DBA or other form of claim.

As the WVA is basically only a pay-to on the DBA, we suggest putting the WVA NPI (1699092718) in  boxes 33A only.  The rendering/treating provider’s NPI goes in 24J and 32A.

The same as the administration claim or any other claim.

The majority of payers will send claim issues notices and remittances to the DBA billing provider which is: Washington Vaccine Association, PO Box 94002, Seattle, WA 98124-9402.  As a provider, you will have entered your rendering/treating provider’s billing office phone number in Box 33 on paper HCFA DBAs or Loop 2000A on electronic DBA submissions. This will enable payers to contact your office by phone if more information, or a corrected DBA is required by the payer.

Additionally, any claim processing issues a payer might have with the DBA will also apply to the separate, traditional administration/office claim that was created on the date of service when the DBA for the vaccine material itself was created.  If you discover and correct an issue with the administration/office claim to ensure your payment, you will need to do the same to resubmit the DBA.

It is the provider’s responsibility to complete the DBA process accurately to avoid denials and to resubmit or respond to payer requests to the same extent as the administration claim. Once the forms reach the payer, it is the payer’s responsibility to send the assessment to the WVA.

In situations where you would rebill for yourself you would also rebill for the WVA. For example, if your administration claim is denied for missing information such as lack of correct member ID or birthdate, you should re-submit the WVA claim at the same time you re-submit the administration claim so the WVA can receive payment.

The DBA or vaccine portion of the visit is billed by the rendering/treating provider and the WVA is basically only a pay-to for the payer to get the payment for the vaccine to the WVA, and the WVA in turn pays into the DOH “fund” for the vaccine material.

It could be the provider’s billing office is not seeing their system generating the DBA claim to you for a couple reasons:  1) they are searching under their own “open balance” claims, and are not seeing their DBA submission because there should be no open balance for the vaccine material payable to them, or, 2) they have a system that generates an open balance to them for the vaccine material then go into the patient account and write off that balance so they don’t receive an overpayment/or can tell if they have an overpayment for the vaccine material.

The provider’s billing office should review the patient account specifically for any charges whether open or not, on the day the patient received the shot/material, which will show their administration/office visit claim, and their vaccine material submission claim should be on that day as well.

The DOH administration fee cap is found on Page 8, #6 of the DOH Provider Agreement:  Enrollment Packet.  This applies a $23.44 cap to all patients/parents (federal and state eligible) who may be paying the administration/office visit portion of the service “out of pocket”.

If the patient has commercial insurance but is required to pay the administration/office visit portion of the service “out of pocket,” either because of a coverage cap, deductible, out of network, etc., then the DOH $23.44 administration fee cap applies.

However, if the commercial insurance is paying the administration/office visit portion, then the cap doesn’t apply and the charge and payment should align with the provider and payer’s contracted allowable amounts.

The assessment grid contains the per dose assessment rate remitted by payers to the WVA. The grid contains the CPT code, NDC code, and vaccine trade name in addition to the assessment rate. Beginning with the 2020-21 grid, it includes a listing of prior discontinued NDC and CPT codes at the end of the document for legacy referencing.

The grid is updated annually and is in effect from July 1 – June 30.  It is expected that providers will submit a dosage-based assessment (DBA) to the patient’s private insurance carrier or third-party administrator in the amount found on the grid, and that the carrier will remit that amount to the WVA.

To ensure proper DBA submission and carrier/TPA remittance to the WVA, please check the:

• Date of service to ensure the correct grid is being used;
• CPT code to ensure it is a valid code (*see note below); and
• Assessment amount to ensure proper DBA submission and carrier/TPA remittance to the WVA.

*Please note:  Sometimes rendering providers can obtain vaccine material that is still viable and can administer it, even if it has been discontinued from prior grids and not showing on the current grid. If the CPT code is not offered on the current grid, providers should check the legacy information at the end of the grid document, and if a code was offered on a past WVA grid the last published assessment amount is what should be remitted to the WVA.

The new pricing grid for WVA vaccine material is updated each July 1, and runs through June 30 of the following year.  This requires updating of “fee schedules” for both providers and payers to ensure the WVA receives proper payment.

The WVA updates the WVA Assessment Grid annually, following CDC rate changes effective April 1. If unique situations arise, the WVA Assessment Grid may be reviewed and update more often than annually.

If you normally bill the state insurance plan or the Health Care Authority (HCA) for the vaccine, continue to do so. If you normally bill the private insurance carrier, use the DBA process.

DBA Form Sample (pdf)

Completed samples of the two forms required for the dosage-based assessment (DBA) process.

Electronic Form (pdf)

Crosswalk that shows the fields and data for the electronic form format as compared to paper CMS 1500 format.

Washington Vaccine Association Assessment Grid

Chart listing the dosage-based assessment charges for vaccines covered by the state’s Childhood Vaccine Program.

The COVID-19 vaccine commercialization went into effect September 14, 2023. For information please use the WVA COVID-19 page at this link:

COVID-19 | Washington Vaccine Association (wavaccine.org)

The WVA is defined as a Public Health & Welfare agency under the provider identification and billing taxonomy code 251K00000X. Washington State’s universal vaccine program requires payer payment to the WVA regardless of contractual status between the payer and the provider. Additionally, the WVA is not required to be in network with the payer. This means that a provider will bill the payer via the DBA process with the WVA as the pay-to billable provider.

It is highly possible that payer adjudication systems will filter out and reject non-network providers, whether rendering, or billable, on the DBA submission. Providers can assist in the DBA submission process by reviewing the following WVA Private Insurance Assessment Billing Provider & Payer Guide (pgs. 3 & 4) for vaccine material assessment and adding a notation on DBA claims as follows: for paper billing, in Box 19 “WVA does not need to be in network for grid payment”, or electronically the same phrase in loop 2300, seg./element NTE01, qualifier Add.

It will also assist the payer to process the DBA correctly if providers be sure to include the WVA taxonomy code (251K00000X) as follows:  for paper billing, in Box 33b, or electronically in loop 2000a, seg./element PRV02, qualifier PXC.

To be proactive, the WVA suggests the provider reach out to their payer representative(s) to confirm they are prepared to recognize and process the DBAs correctly.

No.  The patient should be considered uninsured and vaccine material billed accordingly, outside of the WVA, DBA process.

Health care sharing plans are not regulated by the Washington State Office of the Insurance Commissioner and therefore are not considered health insurance nor are they required to remit DBA payments. Providers should be processing them as uninsured patients according to the Department of Health (DOH) policy statement found at this link.

For each administered vaccine, you must now submit two forms, or two electronic submissions, to the appropriate health plan, insurance company, or TPA:

• The usual CMS 1500 form or electronic submission for the administration of the vaccine, office visit, and other charges, just as you always have, but without the vaccine codes and modifiers. (The payer reimburses you directly for these )
• A second CMS 1500 form or electronic submission that contains the vaccine codes, the dosage-based assessment (DBA) charges, which you’ll find on the WVA Assessment Grid, and our tax ID number: 27-2251833. You may want to review the DBA Form Sample.

The payer reimburses you for vaccine administration and office charges and pays the WVA for the state-supplied vaccine. We then transfer the funds to the state to continue purchasing the vaccines.

Yes.  In the spring of 2020, changes were made to improve the DBA process to decrease errors and confusion at both the provider and payer levels.  While this may require changes in your workflows and electronic practice management systems, your efforts to participate and comply with the program ensure that Washington’s children receive vaccinations.

NPI Number Placement (the WVA NPI # is:  1699092718)

Taxonomy Codes (the WVA Taxonomy # is:  251K00000X)

Phone Number on the DBA (the WVA Phone # is:  888-928-2224)

If you already submit electronically or are converting to electronic claims submission, please continue to do so. Simply submit the DBA information to the appropriate payer listing the WVA as the billing provider. The information should also contain:

• CPT code for the state-supplied vaccine — without modifiers
• Vaccine assessment charge found on the WVA Assessment Grid.
• WVA tax ID: 27-2251833
• WVA mailing address: P.O. Box 94002, Seattle, WA 98124-9402

Electronic billing requirements require the billing provider to fill in a physical address. However, to ensure that payments are sent directly to the secure WVA lockbox, please continue to use the WVA P.O. address for payment information.

• Fill in the “Pay-To Address” for the WVA with the WVA lockbox information: P.O. Box 94002, Seattle, WA 98124-9402 (Loop 2010AB)
• Fill in the “Billing Provider Address” for the WVA with the WVA physical address: Washington Vaccine Association, Marketplace Tower PH-A, 2025 First Avenue, Seattle, WA 98121
• WVA’s NPI #: 1699092718 (Loop 2010AA)

We advise you to notify your claim clearinghouse if you intend to submit the electronic form. You may also want to review our sample Electronic Form (PDF).

Please advise your clearinghouse that you’ll be using the DBA process, with our name, Tax ID, and NPI. Our guide has specific information for you to review with your electronic medical records partners, down to the coding used to successfully transmit the DBA information, as well as a field to add notes to the payer.  If you run into problems, contact us at info@wavaccine.org.

The physical address for the WVA is an administrative address which should not be used as our pay-to address or for any form of communication. Electronic submissions require use of PO Box 94002, Seattle, WA  98124-9402, including  Loop 2010AB.  The physical address is required on your electronic medical records (EMR) system when submitting DBAs electronically in Loop 2010AA.  The current physical address is: 1700 Seventh Ave., Suite 1810, Seattle, WA  98101 (formerly Marketplace Tower PH-A, 2025 First Ave, Seattle, WA).

There should be no change in the way you bill or work with Medicaid and Medicaid managed- care plans for children covered by those plans.

No. Neither the federally funded Vaccines for Children Program entitlement, nor the state’s purchase of vaccines for children in state-sponsored medical plans are affected by the WVA.

DBA forms are not required for uninsured children. Bill those patients for services as you usually do, providing vaccines at no cost through Washington’s Childhood Vaccine Program. Complete the reporting requirements for the Childhood Vaccine Program through your regular vaccine accountability reporting process.

All health plans are required to follow HIPAA guidelines when sending sensitive materials to members. You may want to advise patients to contact their health plans to find out what measures can be taken to protect their privacy in such situations.

Out-of-state payers may engage in our program as out-of-state covered lives under age 19 who are vaccinated by a State of Washington provider in Washington with material via the DOH CVP program that is on the WVA grid can receive the material at no cost via the DBA claim process.

If there is private health plan coverage for the vaccine, it doesn’t matter if it’s an out-of-state patient who gets the vaccine.  A DBA from the provider is submitted to the payer, who in turn issues payment to the WVA.  The WVA in turn helps to “fund” the DOH CVP pool for the material.

No.  The patient should be considered uninsured and vaccine material billed accordingly, outside of the WVA, DBA process.

Health care sharing plans are not regulated by the Washington State Office of the Insurance Commissioner and therefore are not considered health insurance nor are they required to remit DBA payments. Providers should be processing them as uninsured patients according to the Department of Health (DOH) policy statement found at this link.

The DBA or vaccine portion of the visit is billed by the rendering/treating provider and the WVA is basically only a pay-to for the payer to get the payment for the vaccine to the WVA, and the WVA in turn pays into the DOH “fund” for the vaccine material.

It could be the provider’s billing office is not seeing their system generating the DBA claim to you for a couple reasons:  1) they are searching under their own “open balance” claims, and are not seeing their DBA submission because there should be no open balance for the vaccine material payable to them, or, 2) they have a system that generates an open balance to them for the vaccine material then go into the patient account and write off that balance so they don’t receive an overpayment/or can tell if they have an overpayment for the vaccine material.

The provider’s billing office should review the patient account specifically for any charges whether open or not, on the day the patient received the shot/material, which will show their administration/office visit claim, and their vaccine material submission claim should be on that day as well.

The WVA is defined as a Public Health & Welfare agency under the provider identification and billing taxonomy code 251K00000X. Washington State’s universal vaccine program requires payer payment to the WVA regardless of contractual status between the payer and the provider. Additionally, the WVA is not required to be in network with the payer. This means that a provider will bill the payer via the DBA process with the WVA as the pay-to billable provider.

It is highly possible that payer adjudication systems will filter out and reject non-network providers, whether rendering, or billable, on the DBA submission. Providers can assist in the DBA submission process by reviewing the following WVA Private Insurance Assessment Billing Provider & Payer Guide (pgs. 3 & 4) for vaccine material assessment and adding a notation on DBA claims as follows: for paper billing, in Box 19 “WVA does not need to be in network for grid payment”, or electronically the same phrase in loop 2300, seg./element NTE01, qualifier Add.

It will also assist the payer to process the DBA correctly if providers be sure to include the WVA taxonomy code (251K00000X) as follows:  for paper billing, in Box 33b, or electronically in loop 2000a, seg./element PRV02, qualifier PXC.

To be proactive, the WVA suggests the provider reach out to their payer representative(s) to confirm they are prepared to recognize and process the DBAs correctly.