CurrentUnitedHealthcarePolicy N/A

Vaccines for Children (VFC) reimbursement

Policies governing reimbursement coding and billing for Vaccines for Children program immunizations for UnitedHealthcare Community Plan Medicaid members under age 19, including state-specific modifier and billing rules.

Policy Summary

PayerUnitedHealthcare

PolicyVaccines for Children (VFC) reimbursement

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit vaccine and administration codes on the same date of service by the same provider and ensure units match.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

19diseases listed as included in VFC program

age 0-18members covered by this VFC reimbursement policy

90460,90471-90474administration CPT codes required/preferred

90461administration code not reimbursable

multiplestates with modifier variations

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Vaccines for Children (VFC) Coverage Criteria

VFC coverage criteria

Coverage applies to Medicaid members under age 19; reimbursement follows CMS/PPACA direction with state-specific exceptions.

Applies to members birth through 18 years + 364 days

Medicaid programs must reimburse VFC services on administration codes 90460 and/or 90471-90474 rather than the serum/toxoid code; CPT code 90461 is not reimbursable for VFC services per PPACA/CMS guidance

Vaccine code(s) and administration code(s) may be submitted on separate claims only if claims are for the same date of service by the same provider

The number of administration units must equal the number of vaccine units on the same-date claim; excessive units will be denied

Some states require specific modifiers appended to serum and/or administration codes (e.g., SL, SE, EP); follow State Fee‑for‑Service communications for required modifiers and State Exceptions

State payment variations

Some states pay on the serum (vaccine) code rather than the administration code and may not require an administration code on the claim
Some states reimburse only 90460 for VFC-administered vaccines while others reimburse multiple administration codes (90460, 90471-90474); refer to State Exceptions for payable codes in each state

Separate payment for an office or well-child visit is allowed when documentation supports a separately identifiable visit; append modifier 25 to the visit code

CHIP participation

Some state-specific CHIP products do not participate in the VFC program (see State Exceptions)

Administration and Coding Requirements

VFC administration codesCPTCovered

90460	Immunization administration under VFC program (per policy guidance)
90471	Vaccine administration (pediatrics) — included per CMS direction
90472	Vaccine administration (pediatrics) — included per CMS direction
90473	Vaccine administration (pediatrics) — included per CMS direction
90474	Vaccine administration (pediatrics) — included per CMS direction

VFC administration codes - not reimbursableCPTNot Covered

90461

Not reimbursable for VFC services per PPACA/CMS guidance

Units must match — billing threshold

RequirementNumber of administration units must equal number of vaccine units on the same date of service by the same provider; excessive units will be denied.

Claim submissionVaccine and administration codes may be submitted on separate claims only if they are for the same date of service by the same provider and units match.

Example denialIf vaccine 90696 billed 1 unit but administration 90472 billed 2 units, the unmatched extra unit will be denied.

Billing, Submission, and Provider Instructions

Billing Rule

Administration code usage and visit payment

Report administration codes and vaccine codes correctly to ensure payment and avoid denials. For Vaccines For Children (VFC) vaccine administrations, use CPT code 90460; CPT code 90461 is not reimbursable for VFC services and must not be used to report each vaccine toxoid component of a combination vaccine. Vaccine administration codes 90471–90474 should not be used for VFC-covered vaccines when state guidance requires 90460. When 90460 is payable in a state, report 90460 on each claim line along with the corresponding vaccine toxoid CPT code; 90460 should be repeated on multiple detail lines to reflect the total number of administrations performed. The total number of 90460 detail lines must equal the total number of VFC vaccine toxoid codes administered. Submit a $0.00 charge with the toxoid code when required by the claims payment system. Separate payment for an office or well visit may be allowed if documentation supports a separately identifiable visit; append modifier 25 to the visit code to indicate this.

Use CPT 90460 for VFC-administered vaccines; do NOT use CPT 90461 for VFC services.
Do not report 90471–90474 for VFC-covered vaccines when state guidance requires 90460.
Report 90460 on each claim line with each vaccine toxoid CPT code administered; number of 90460 lines must equal number of toxoid codes.
Submit a $0.00 charge with vaccine toxoid codes when required by the state/claims system.
A separately payable office/well visit requires modifier 25 on the visit code with supporting documentation.

Billing Rule

Billing and submission requirements

When billing for vaccines and administration, submit the vaccine CPT/HCPCS code(s) and the appropriate administration code(s) on the same date of service by the same provider. Units billed for vaccine and administration must match exactly; excessive or mismatched units will be denied (for example, billing one unit of administration but no corresponding vaccine unit will deny). Some states require modifiers on the serum/toxoid code(s) and/or the administration code(s); follow your State Fee-for-Service Medicaid Plan communications for state-specific modifier and administration code payment variations.

Vaccine and administration codes may be submitted on separate claims only if same date of service and same provider, and units match.
Excessive or mismatched units will be denied (units must correspond 1:1).
Some states require modifiers on vaccine and/or administration codes — consult state-specific guidance for exceptions and payable administration codes.

Definitions and Modifiers

VFC — Vaccines for Children (definition)

Program definitionVaccines for Children (VFC) provides federally funded vaccines for eligible children up to 18 years + 364 days, including Medicaid-eligible, uninsured, American Indian/Alaska Native, and those whose insurance doesn't cover immunizations.

ScopeACIP-recommended vaccines with VFC resolutions and federal contracts are included; generally combined antigen vaccines are provided; single antigen vaccines only when combined antigen is contraindicated and documented.

Age eligibilityApplies to children from birth through 18 years of age (18 years + 364 days).

CHIP — Children's Health Insurance Program (definition)

Program nameChildren's Health Insurance Program (CHIP).

State variationsSome state CHIP products do not participate in the VFC program (see State Exceptions for details).

ReferenceState-specific exclusions and participation are listed in the State Exceptions section of the policy.

Modifiers (SE, SL, EP) — meanings and examples

SEState or Federally Funded Program modifier; e.g., Maryland requires the SE modifier on the serum code effective 9/1/13 — failure to append will result in denial.

SLState Supplied modifier; multiple states (Arizona, Indiana, Minnesota, Missouri, Nebraska, New York, etc.) require SL appended to serum and/or administration codes — omission can cause denials.

EPState-specific modifier (example: Mississippi uses EP for MSCAN) required on administration and serum codes for certain programs — omission can cause denials.

State guidanceRefer to State Fee for Service communications and the State Exceptions section for exact modifier requirements by state.