CurrentMass General Brigham Health PlanPolicy N/A

Vaccine and immunization administration reimbursement

Policy Summary

PayerMass General Brigham Health Plan

PolicyVaccine and immunization administration reimbursement

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateJan 1, 2025

Key ActionSubmit one CPT vaccine/toxoid product code per administered product on a single claim line with a count of one, append modifier SL when vaccine is state-supplied, and submit the appropriate administration code(s).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

90460-90748Primary CPT code ranges referenced for vaccines and administration

SLModifier for State-supplied vaccine (not reimbursed)

MultipleDocument revision history (last annual review noted)

Policy Snapshot

Defines Mass General Brigham Health Plan reimbursement rules for vaccine/toxoid products and administration codes for contracted providers. Applies to claims processing and payment for immunization services for plan members, with references to Commercial and MassHealth/MyCareFamily guidance. Policy status: CURRENT. Providers are reimbursed per contracted rates and claims are subject to payment edits and member benefit determinations; referral/prior authorization requirements and plan-specific member liabilities (copays, deductibles, coinsurance) may apply.

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Code Groups and Modifiers

Vaccine administration (pediatric with counseling)CPTCovered

90460	Immunization administration through 18 years; first or only component with counseling
90461	Each additional vaccine/toxoid component with counseling (add-on)

Vaccine administration (no counseling or adult)CPTCovered

90471	Immunization administration, one vaccine (single or combination) - no face-to-face counseling or for patients >18
90472	Immunization administration, one vaccine, each additional vaccine product (add-on to 90471)
90473	Immunization administration oral or intranasal; one vaccine product - no counseling or adult
90474	Immunization administration oral/intranasal, each additional vaccine product (add-on to 90473)

Vaccine product codes (examples)CPT

90680	Rotavirus vaccine, oral
90700	DTaP (IM) vaccine product
90714	Td vaccine product

Vaccine product code range referenceCPT

90620-90748

Referenced CPT vaccine/toxoid product codes (per CPT Manual)

Modifier for state-supplied vaccineModifierNot Covered

SL	State Supplied Vaccine — Not reimbursed

Billing, Documentation, and Authorization Requirements

Billing Rule

State-supplied vaccine billing

Append modifier SL in the first modifier field to CPT vaccine/toxoid product codes when the vaccine is state-supplied; SL-coded vaccine products are not reimbursed. Post-payment audits may be used to confirm compliance.

Documentation Required

Counseling and medical record documentation

For children ≤18, document pediatric vaccine immunization counseling in the member's medical record when billing 90460/90461. Providers may need to provide state documentation in case of privately purchased vaccine reimbursement requests during documented shortages.

Prior Authorization

Referral and prior authorization

Various services and procedures may require referral and/or prior authorization per the member's benefit; check the plan's referral and prior authorization resources.

Denial Risk

Non-reimbursable scenarios

Do not expect reimbursement for listed non-reimbursable scenarios, including combined vaccines when individual components are available and supplied by a government entity; vaccines supplied at no cost under government programs when the provider is eligible; vaccines not FDA-approved; vaccines given for workplace requirements; vaccine administration codes reported without the vaccine product code; and unlisted services and procedures.

Context and Scope

This guideline covers covered immunization services and reimburses adult and pediatric vaccine administration when not billed with an E/M service. It does not apply to immunoglobulins, serum or recombinant products. The plan does not reimburse for vaccines provided at no cost under government distribution programs when the provider is eligible to receive such vaccines, for vaccines not FDA-approved, for workplace-required vaccines, or for vaccine administration codes billed without an accompanying vaccine product code. Mass General Brigham Health Plan may use post-payment audits to confirm compliance with state-supplied vaccine billing.

Providers must submit one CPT vaccine/toxoid product code per administered product on a single claim line with a count of one, and report the appropriate administration code. For pediatric administrations with counseling, use 90460 for the first component and 90461 for each additional component. For adult administrations or those without face-to-face counseling use 90471-90474 with corresponding add-on codes as needed. Append modifier SL in the first modifier field when the vaccine is state-supplied; SL-coded vaccine products are not reimbursed.

Publication and Review History

2009-10-01publication

Original documentation published.

2012-08-01update

Codes updated; disclaimer updated; travel vaccines added; some codes removed.

2018-05-01update

Template and language updates; codes updated.

2019-01-01restructure

Document restructure and codes updated.

2023-01-01rebrand

Document rebrand and references updated.

2024-01-01annual_reviewLatest

Annual review; no policy change.

2025-01-01planned_review

Planned annual review noted in document.