CurrentAnthemPolicy G-05022

Reimbursement Policy Vaccines for Children (VFC) Program

Defines Anthem Wisconsin reimbursement rules for vaccine administration for members eligible for the VFC Program (children 18 and under) and related scenarios including non‑VFC vaccines, office visit reimbursement, and state supply shortages.

Policy Summary

PayerAnthem

PolicyVaccines for Children (VFC) Program reimbursement

Policy CodePolicy G-05022

Change TypeAdded modifier SL

Effective DateJul 21, 2025

Next Review Date

Key ActionInclude applicable serum and administration codes and modifiers (including SL) on claims to meet reporting requirements and ensure reimbursement.

SourceLink

POLICY UPDATE CHANGES

Added modifier SL for vaccine administration reimbursement.

18 yearsVFC age limit

CDC maxAdministration fee cap

ReimbursedSerum reimbursement during shortages

AllowedMinimal office visit

VFC Program Vaccine Administration Coverage

VFC and vaccine administration coverage criteria

Reimbursement rules for vaccine administration and serum for VFC and non‑VFC situations.

Health plan reimburses the administration fee for vaccines provided by the Vaccines for Children (VFC) Program for eligible members 18 years of age and younger, unless provider, state, federal, or CMS contracts and/or requirements indicate otherwise.

Reimbursement for administration is based on the fee schedule or contracted/negotiated rate up to maximum fee limits set by the Centers for Disease Control and Prevention (CDC) and applicable modifier SL.

The health plan does not reimburse providers for the vaccine serum when provided through the VFC Program; serum is provided free of charge through VFC.

Serum code(s) must still be included on the claim along with administration codes and applicable modifiers (including SL) to meet regulatory and HEDIS reporting requirements; claims missing applicable serum and administration codes or modifiers may not be eligible for reimbursement.

The health plan does not allow separate reimbursement for the administration code.

A minimal office visit is separately reimbursable when vaccine administration is the only service performed.

For members or vaccines not eligible under the VFC Program, the health plan reimburses both administration and serum based on the fee schedule or a contracted/negotiated rate.

During documented state VFC program supply shortages, the health plan will reimburse providers for serum(s) based on fee schedule or contracted/negotiated rate and applicable modifiers; health plans will track state VFC Program and CDC information to monitor shortages.

These policies may be superseded by provider, state, federal, or CMS contracts and requirements; providers must follow applicable mandates.

Vaccine Administration and Serum Coding

VFC vaccine administration and serum codingCPT | HCPCS | mixedCovered

Vaccine administration codes must be billed; serum codes must be included on claim even if serum is provided free through VFC to meet reporting requirements.

CDC maximum fee limits — administration reimbursement cap

Reimbursement capAdministration reimbursement is based on the fee schedule or contracted/negotiated rate up to maximum fee limits set by the Centers for Disease Control and Prevention (CDC)

Modifier requirementReimbursement is subject to use of modifier SL as applicable per regulatory directive

VFC serum policyThe health plan does not reimburse providers for the vaccine serum when provided through the VFC Program; serum is provided free of charge

Claims and reportingSerum code(s) must be included on the claim along with administration codes and modifiers to meet regulatory and HEDIS reporting requirements; claims missing these may not be eligible for reimbursement

ApplicabilityApplies to VFC‑eligible members 18 years of age and younger unless superseded by provider, state, federal, or CMS contracts/requirements

Claim Submission and Authorization Notes

Billing Rule

Claim Submission and Authorization Notes

Ensure claims include both the applicable vaccine serum code(s) and the vaccine administration code(s), and apply modifier SL where required. Although the plan does not reimburse the vaccine serum when provided through the Vaccines for Children (VFC) Program, serum codes must still be reported to satisfy regulatory and HEDIS reporting requirements. Claims submitted without the applicable serum and administration codes and required modifiers may be rejected, denied, or deemed ineligible for reimbursement.

Include applicable serum CPT/HCPCS code(s) on the claim even when serum is provided at no charge (VFC).
Include the appropriate vaccine administration CPT code(s).
Apply modifier SL when applicable per fee schedule/contract and regulatory guidance.
Claims without both serum and administration codes and required modifiers may be rejected, denied, or recouped.
Reimbursement is limited to the administration fee; separate reimbursement for serum is not allowed when provided through VFC.

Key Definitions

Minimal Office Visit — definition

DefinitionMinimal Office Visit: Office or other outpatient visit for the evaluation and management of an established patient that may not require the presence of a physician or other qualified healthcare professional.

Reimbursement allowanceA minimal office visit is separately reimbursable when vaccine administration is the only service performed

Context of useUsed when vaccine administration is the sole service to clarify that an office visit may still be billed and reimbursed separately

DocumentationClaims must include applicable administration and serum codes and modifiers to meet reporting and reimbursement requirements even when only a minimal visit occurs

Policy Summary

PayerAnthem

PolicyVaccines for Children (VFC) Program reimbursement

Policy CodePolicy G-05022

Change TypeAdded modifier SL

Effective DateJul 21, 2025

Next Review Date

Key ActionInclude applicable serum and administration codes and modifiers (including SL) on claims to meet reporting requirements and ensure reimbursement.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

VFC Program Vaccine Administration Coverage

VFC and vaccine administration coverage criteria

Reimbursement rules for vaccine administration and serum for VFC and non‑VFC situations.

The health plan does not reimburse providers for the vaccine serum when provided through the VFC Program; serum is provided free of charge through VFC.

The health plan does not allow separate reimbursement for the administration code.

A minimal office visit is separately reimbursable when vaccine administration is the only service performed.

For members or vaccines not eligible under the VFC Program, the health plan reimburses both administration and serum based on the fee schedule or a contracted/negotiated rate.

These policies may be superseded by provider, state, federal, or CMS contracts and requirements; providers must follow applicable mandates.

Vaccine Administration and Serum Coding

VFC vaccine administration and serum codingCPT | HCPCS | mixedCovered

Vaccine administration codes must be billed; serum codes must be included on claim even if serum is provided free through VFC to meet reporting requirements.

CDC maximum fee limits — administration reimbursement cap

Reimbursement capAdministration reimbursement is based on the fee schedule or contracted/negotiated rate up to maximum fee limits set by the Centers for Disease Control and Prevention (CDC)

Modifier requirementReimbursement is subject to use of modifier SL as applicable per regulatory directive

VFC serum policyThe health plan does not reimburse providers for the vaccine serum when provided through the VFC Program; serum is provided free of charge

ApplicabilityApplies to VFC‑eligible members 18 years of age and younger unless superseded by provider, state, federal, or CMS contracts/requirements

Claim Submission and Authorization Notes

Billing Rule

Claim Submission and Authorization Notes

Include applicable serum CPT/HCPCS code(s) on the claim even when serum is provided at no charge (VFC).
Include the appropriate vaccine administration CPT code(s).
Apply modifier SL when applicable per fee schedule/contract and regulatory guidance.
Claims without both serum and administration codes and required modifiers may be rejected, denied, or recouped.
Reimbursement is limited to the administration fee; separate reimbursement for serum is not allowed when provided through VFC.

Key Definitions

Minimal Office Visit — definition

Reimbursement allowanceA minimal office visit is separately reimbursable when vaccine administration is the only service performed

Context of useUsed when vaccine administration is the sole service to clarify that an office visit may still be billed and reimbursed separately

DocumentationClaims must include applicable administration and serum codes and modifiers to meet reporting and reimbursement requirements even when only a minimal visit occurs

OpenPayer

Reimbursement Policy Vaccines for Children (VFC) Program

VFC Program Vaccine Administration Coverage

Vaccine Administration and Serum Coding

Claim Submission and Authorization Notes

Key Definitions

OpenPayer

Reimbursement Policy Vaccines for Children (VFC) Program

VFC Program Vaccine Administration Coverage

Vaccine Administration and Serum Coding

Claim Submission and Authorization Notes

Key Definitions