Vaccines For Children (VFC) reimbursement
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Defines Healthfirst New York's reimbursement procedures for Vaccines for Children (VFC) for eligible children under age 19 and applies to the Child Health Plus line of business; aligns with NYS Medicaid and ACIP/CDC recommendations.
14 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
ALL of the following
- Age eligibility: Patient is under 19 years of age per policy.
- Vaccine is recommended by ACIP and provided via the VFC program.
- Provider is enrolled as a VFC provider through the Citywide Immunization Registry (CIR) and has completed required CDC VFC training.
ALL of the following
- Administration reimbursement: Claim is for vaccine administration and billed using one of the reimbursable administration CPT codes: 90460 or 90471-90474.
- Vaccine product cost: Vaccine product supplied by the VFC program or other funded programs — vaccine cost is not reimbursed by Healthfirst.
- Documentation and timely filing: Provider maintains comprehensive documentation including eligibility verification and vaccine administration records and submits claims in accordance with provider contract and timely filing requirements.
Coverage context and billing rules
Context and billing rules to apply when submitting VFC-related claims:
Applicable CPT/HCPCS and Administration Codes
| 90460 | Immunization administration through 18 years of age via any route with counseling; first or only |
| 90471 | Immunization administration; 1 vaccine (single or combination) |
| 90472 | Each additional vaccine (list separately) |
| 90473 | Immunization administration by intranasal or oral route; 1 vaccine |
| 90474 | Immunization administration by intranasal or oral route; each additional vaccine |
| 90632-90696,90700-90749,90375-90396,90378-90382,90680-90683 | Applicable vaccine and immune globulin HCPCS/CPT vaccine product codes listed in the policy (extensive list) |
| 90707 | Measles, mumps and rubella virus vaccine (MMR), live, for subcutaneous use. |
| 90710 | Measles, mumps, rubella, and varicella vaccine (MMRV), live, for subcutaneous use. |
| 90713 | Poliovirus vaccine, inactivated (IPV), for subcutaneous or intramuscular use. |
| 90714 | Tetanus and diphtheria toxoids adsorbed (Td), preservative free, for intramuscular use (ages 7+). |
| 90715 | Tdap, for intramuscular use (ages 7+). |
| 90716 | Varicella virus vaccine (VAR), live, for subcutaneous use. |
| 90717 | Yellow fever vaccine, live, for subcutaneous use. |
| 90723 | DTaP-HepB-IPV, for intramuscular use. |
| 90732 | PPSV23, for subcutaneous or intramuscular use (ages 2+). |
| 90733 | Meningococcal polysaccharide vaccine (MPSV4), for subcutaneous use. |
Provider Enrollment, Billing, and Documentation Requirements
Provider enrollment, SL modifier, documentation, and denial risk
Enroll as a VFC provider through the Citywide Immunization Registry (CIR); complete required CDC training and agree to follow all VFC requirements. Append the SL modifier to claims for federal- and state-funded vaccines to indicate the vaccine was provided through VFC; failure to use the SL modifier may result in incorrect reimbursement. Maintain comprehensive documentation to support claims, including patient eligibility verification, vaccine administration records, and any other relevant medical records; claims that do not adhere to documentation requirements may be denied or rejected.
- Providers must enroll through the Citywide Immunization Registry (CIR) and complete CDC-required training (VFC participation prerequisite).
- The SL modifier must be appended to claims for federal/state-funded vaccines to indicate VFC-supplied vaccine.
- Maintain patient eligibility verification, vaccine administration records, and other relevant medical records to support claims.
- Claims noncompliant with these requirements may be denied or rejected.
Claims editing, coding standards, and potential denials/recoupment
Claims are subject to Healthfirst claim edits that follow national industry standards (CMS/NCCI, NCD/LCD, CPT/HCPCS/ICD-10 principles, and New York State-specific policies). Failure to follow proper coding, modifier usage, and timely filing requirements can result in claim denials, rejections, or recoupment.
- Healthfirst claim edits incorporate NCCI, NCD/LCD, CPT/HCPCS/ICD-10 coding principles and other national/state guidelines.
- Improper coding, incorrect modifier use, or failure to meet timely filing requirements may lead to denial, rejection, or recoupment.
Definitions and Program Terms
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