Pediatric practices. Every dose, every well visit, billed to the plan that owes it.

In many states Medicaid pays through managed-care plans, and federal rules require each plan's network providers to be enrolled with the state as well.^A In those states, one pediatrician enrolls with the state, then with each plan.

Practices registered with Vaccines for Children receive that stock free, so for a Medicaid child the practice is paid an administration fee, capped at a ceiling set for each state, and nothing for the dose. Children in a separate CHIP program are not eligible for those doses.^B Each child's coverage decides which stock a dose comes from.

Administration is reported with CPT 90460 and 90461 or with 90471 to 90474, depending on the child's age and whether the physician counseled the family. When a sick visit happens on the same day as the shots, it is billed only if it is significant and separately identifiable, with modifier 25.^C

A well visit that turns sick is paid by each plan's own rule. UnitedHealthcare's commercial policy pays the preventive visit plus 50% of the problem-oriented visit when modifier 25 is attached, and nothing for the problem visit without it.^D We bill each plan to its own rule.

Newborns are seen before they have a member ID of their own. A baby born to a mother on Medicaid is covered from birth without an application.^E A commercial plan waits for the parents to add the baby. We confirm coverage before those first claims go out.

Well-child visits and recommended immunizations are generally covered at no cost to the family when an in-network provider delivers them, and Medicaid's EPSDT benefit covers preventive care for enrolled children under age 21.^{B, F} Both only work for a practice the plan has on file.