Vaccines For Children (VFC)
Customize your policy alerts
Sign up for healthfirstofnewyork Policy PO-RE-081v3 alerts
Get alerted when Policy PO-RE-081v3 changes without checking for updates manually.
Monitor payer policy activity
Defines Healthfirst reimbursement and billing requirements for Vaccines for Children (VFC) services for eligible children under 19, and explains provider responsibilities for program enrollment and documentation. Applies to specified Healthfirst lines of business including Child Health Plus and Medicaid Managed Care.
Reimbursement under the VFC policy is administered in accordance with applicable federal and New York State laws, regulations, Medicaid requirements, and VFC program guidance.
Policy Scope language was broadened to recognize vaccines covered under applicable federal and New York State requirements, including NYSDOH and Commissioner of Health recommendations in addition to ACIP.
A new Pharmacist Administration section clarifies reimbursement requirements for vaccines administered by licensed pharmacists, including compliance with New York State law, NYSDOH requirements, member benefits, provider participation, billing requirements, and documentation standards.
Fourteen CPT codes were added to the Applicable Codes section.
Vaccines for Children (VFC) Coverage Criteria
VFC coverage criteria
Covered when ALL of the following are met:
ALL of the following
- Patient is under 19 years of age (eligible children)
ALL of the following
- Provider is enrolled in the Citywide Immunization Registry (CIR) and has completed CDC-required VFC training
- Provider agrees to follow all VFC program requirements as a condition of reimbursement
ALL of the following
- Vaccine product supplied by the VFC program or other funded programs is NOT reimbursed by Healthfirst
- Healthfirst will reimburse administration costs only for vaccines billed under the VFC program using CPT codes 90460, 90471-90474
- Claims for federal/state-funded vaccines must include the SL modifier as applicable
ALL of the following
- Applies to Child Health Plus and Medicaid Managed Care lines of business
Coverage governance and claim adjudication
Reimbursement and claim adjudication are governed by applicable federal and New York State laws, Medicaid requirements, NYSDOH guidance, and Healthfirst coding/adjudication rules.
ALL of the following
- Claim edits incorporate NCCI, NCD/LCD, CPT/HCPCS and ICD-10 principles, revenue coding guidelines, and New York State–specific coding/billing policies
- Failure to follow coding, billing, or documentation requirements may result in denial, rejection, or recoupment
Applicable Codes and Billing Rules
| 90460 | Immunization administration through 18 years with counseling; first or only |
| 90471 | Immunization administration; 1 vaccine |
| 90472 | Immunization administration; each additional vaccine |
| 90473 | Immunization administration by intranasal or oral route; 1 vaccine |
| 90474 | Immunization administration by intranasal or oral route; each additional vaccine |
| 90611-90694, 90710-90723 (selected) | Range of vaccine product codes listed as applicable to VFC program (multiple vaccine CPT/HCPCS codes included) |
| 90710 | Measles, mumps, rubella, and varicella vaccine (MMRV) |
| 90717 | Yellow fever vaccine, live, for subcutaneous use |
| 90732 | Pneumococcal polysaccharide vaccine, 23-valent (PPSV23) |
| 90733 | Meningococcal polysaccharide vaccine, MPSV4 |
| 90734 | Meningococcal conjugate vaccine, MenACWY |
| 90736 | Zoster (shingles) vaccine, live |
| 90738 | Japanese encephalitis virus vaccine, inactivated |
| 90739 | Hepatitis B vaccine (adult CpG-adjuvanted) |
| 90740 | Hepatitis B vaccine (dialysis/immunosuppressed dosage) |
| 90743 | Hepatitis B vaccine, adolescent, 2 dose schedule |
Provider Enrollment, Billing, and Appeals
Enroll in CIR and complete CDC-required VFC training
Providers who wish to participate in the VFC program must enroll through the Citywide Immunization Registry (CIR) and agree to follow all VFC requirements. VFC providers are required to complete the training mandated by the Centers for Disease Control and Prevention (CDC) as a condition of reimbursement.
- Enroll as a VFC provider through the Citywide Immunization Registry (CIR).
- Agree to follow all VFC program requirements.
- Complete CDC-required VFC training prior to participation.
Claims noncompliance may result in denial or rejection; provider responsibility for coding and filing
Claims that do not adhere to this VFC policy will be denied or rejected; providers are responsible for accurate coding and ensuring claims meet timely filing requirements per their provider contract and the Healthfirst Provider Manual. This policy is a resource and does not guarantee payment — final reimbursement depends on benefit coverage, mandates, medical necessity, and provider contract.
- Ensure claims are coded accurately to avoid denial or rejection.
- Comply with timely filing requirements in the provider contract and Healthfirst Provider Manual (see subsection 17.6).
- Use this policy for reimbursement guidance but recognize it does not guarantee coverage or payment.
Reimbursement and claim edit authority — adherence to federal/state laws and coding standards
Healthfirst administers reimbursement and claim edits in accordance with applicable federal and New York State laws, Medicaid requirements, VFC program guidance, and industry/CMS coding standards; failure to follow these coding/billing guidelines may result in denial, recoupment, or claim edits by Healthfirst.
- Reimbursement determinations follow federal and New York State laws, Medicaid requirements, NYSDOH guidance, and VFC program guidance.
- Healthfirst claim edits align with CMS and national industry standards (e.g., NCCI, NCD/LCD, CPT/HCPCS, ICD-10) and New York State-specific policies.
- Noncompliance with coding, billing, or reimbursement guidelines may lead to denial and/or recoupment.
Key Terms and Modifiers
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.