CurrentColorado Rocky Mountain Health PlansPolicy 2026R0060C

Maximum Frequency per Day (MFD) and immunization administration billing rules

Defines MFD values for CPT and HCPCS codes, billing guidance for vaccine administration units, and policy list update history for UnitedHealthcare commercial and individual exchange claims processing. Affects providers submitting CMS 1500 claims to Colorado Rocky Mountain Health Plans (UnitedHealthcare).

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyMaximum Frequency per Day (MFD) and immunization administration billing rules

Policy CodePolicy 2026R0060C

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionReport immunization administration codes per component; avoid duplicate identical procedure code lines to reduce risk of denial as duplicate service.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

100default MFD value used for many new CPT/HCPCS codes when no CMS MUE or claims data exist

10maximum doses per vial for CPT 95165

examplesstatistical method examples

multiplepolicy list update history

Maximum Frequency and Billing Criteria

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyMaximum Frequency per Day (MFD) and immunization administration billing rules

Policy CodePolicy 2026R0060C

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionReport immunization administration codes per component; avoid duplicate identical procedure code lines to reduce risk of denial as duplicate service.

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.

MFD and billing criteria

Billing and MFD criteria applicable to immunization administration and other CPT/HCPCS codes:

Providers may report the administration of each vaccine component on separate lines (for example, multiple lines of 90460 and 90461 with 1 unit each). Duplicate lines with the same procedure code reported on the same or separate claims may be denied as duplicate service.

UnitedHealthcare follows CDC ACIP recommendations to set the MFD value for additional immunization administration codes (for example, CPT 90472 and 90474).

For new CPT/HCPCS codes with no CMS MUE value, claims data, or previous claim history, the default MFD value is set to 100 to allow processing and reduce overpayments from billing or data entry errors; the MFD will be revised when CMS MUE or claims data become available per the MFD determination hierarchy.

Statistical rule for setting MFD from claims percentiles: compare the 98th percentile (A) and the 100th percentile (B). Calculate (A) x 4 = (C). If (B) > (C), set MFD = 98th percentile; otherwise set MFD = 100th percentile.

CMS defines CPT 95165 dose as one 1 cc aliquot from a multidose vial and allows a maximum of 10 doses per vial; providers will not be reimbursed for more than the CMS MFD/MUE value per day.

Code Examples and MFD Determination

Examples and vaccine administration codesCPT

95165	Dose defined by CMS as one 1 cc aliquot from a multidose vial; CMS allows maximum of 10 doses per vial
86902	Example used in statistical MFD calculation (98th = 14, 100th = 27)
E0676	Example used in statistical MFD calculation (98th = 2, 100th = 30)
90460	Immunization administration (can report each vaccine component on separate lines; examples include DtaP, rotavirus, Hepatitis B/Hib, poliovirus, pneumococcal conjugate vaccine)
90461	Immunization administration additional component (examples shown used in multi-component vaccine reporting)
90472	Additional immunization administration code (MFD determined per CDC ACIP recommendations)
90474	Additional immunization administration code (MFD determined per CDC ACIP recommendations)

MFD determination rules

Default MFD for new CPT/HCPCS codesWhen no CMS MUE or historical claims data exist, new codes are assigned an MFD of 100 to allow processing and reduce overpayments from billing/data-entry errors.

Hierarchy for revising MFDOnce CMS MUE or claims data become available, the MFD will be established per the Reimbursement Guidelines MFD determination hierarchy.

Statistical rule using 98th vs 100th percentilesCompare 98th (A) and 100th (B) percentiles: compute (A) x 4 = (C). If B > C, set MFD = 98th; if B ≤ C, set MFD = 100th.

Example: 8690298th = 14, 100th = 27; factor of 4 => 56; since 27 ≤ 56, MFD set at 100th (27).

Example: E067698th = 2, 100th = 30; factor of 4 => 8; since 30 > 8, MFD set at 98th (2).

CMS dose limit for CPT 95165CMS defines a dose as one 1 cc aliquot from a single multidose vial and allows a maximum of 10 doses per vial; providers will not be reimbursed above CMS MFD/MUE per day.

Vaccine Administration Billing Guidance

Billing Rule

Vaccine administration must be billed per component; duplicate lines risk denial

Report immunization administration codes per component; it is appropriate to report the administration of each vaccine component on separate lines (for example, multiple lines of 90460 and 90461 with 1 unit each). When the same CPT or HCPCS procedure code is reported on multiple lines and/or on separate claims, the additional line(s) with the same procedure code may be denied as a duplicate service.

You may report each vaccine component on its own line (e.g., 5 lines of 90460 with 1 unit each and 3 lines of 90461 with 1 unit each).
Duplicate lines with the same CPT/HCPCS code and units may be denied as duplicate service.

MFD Policy Lists and Indicators

MFD assignments — CPT codes

Purpose of CPT MFD Policy ListDesignates the maximum frequency per day value assignments for CPT codes.

Attachment availabilityPolicy includes an attachment listing CPT codes with their assigned MFD values.

Use in claims processingAssigned CPT MFD values are used to limit units of service per date of service during adjudication.

MFD assignments — HCPCS codes

Purpose of HCPCS MFD Policy ListDesignates the maximum frequency per day value assignments for HCPCS codes.

Attachment availabilityPolicy includes an attachment listing HCPCS codes with their assigned MFD values.

Use in claims processingAssigned HCPCS MFD values are applied during claims adjudication to control reimbursable units per date of service.

MAI2 / impossible-units codes and modifier guidance

MAI2 indicator codes definitionCodes CMS identified where Units of Service on the same date exceeding the MUE would be considered impossible; anatomic modifiers may be considered when appropriate.

Modifier handlingFor MAI2 codes, laterality or anatomic modifiers may be accepted when appropriate per the code description (e.g., LT/RT cases).

Relation to MUE/MFD enforcementMAI2 designation signals stricter review: units beyond the MUE on the same date are flagged as impossible unless valid anatomic modifiers justify additional units.

Codes with 'per date of service' languageServices whose descriptions include 'single lesion,' 'XX or more lesions,' or 'per date of service' should be reported with 1 unit of service, consistent with MAI2-like restrictions.