CurrentUnitedHealthcarePolicy N/A

Vaccines for Children (VFC) reimbursement policy

Governs UnitedHealthcare Community Plan Medicaid reimbursement for VFC vaccines and related administration codes for members under age 19, including state-specific billing and modifier requirements.

Policy Summary

PayerUnitedHealthcare

PolicyVaccines for Children (VFC) reimbursement policy

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit vaccine administration using CPT 90460 or 90471-90474 per state guidance; 90461 is not reimbursable for VFC services.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

19VFC diseases listed

age <19member age range

90460,90471-74required admin codes

multiplestates with exceptions

CMS-1500claim form

Vaccines for Children (VFC) Coverage and Billing Rules

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VFC coverage criteria and billing rules

Covered when ALL of the following criteria are met:

ALL of the following

Member age is from birth through 18 years + 364 days (age <19)age <19
Per policy, Medicaid-covered children in this age range are considered VFC eligible
Member is enrolled in Medicaid (including applicable state Medicaid programs) or otherwise meets federal VFC eligibility categories (uninsured, American Indian/Alaska Native, or underinsured as defined by program)

ALL of the following

Report vaccine administration using CPT 90460 or CPT 90471-90474 as allowed by the State Fee-for-Service Medicaid guidance
Per PPACA/CMS, 90461 is NOT reimbursable for VFC services
CODE PAIRING RULE
- Date of service on both claim lines is identical
- Provider NPI/same billing provider on both claim lines
- Number of units billed for vaccine(s) equals number of units billed for administration; excessive units will be denied
MODIFIERS/STATE VARIATION
- Append SL when state requires SL on serum and/or administration codes (state examples: AZ, IN, KS, KY, MN, MO, NE, NY)
- Append SE when state requires SE on the serum code (example: MD)
- Append EP when required by state (example: NC for administration codes; MS for MSCAN)
Follow state-specific payment rules (some states pay on serum code instead of administration code; some states limit which administration codes are payable; state attachments list exceptions)

ALL of the following

Do not bill CPT 90461 for VFC services — 90461 is not reimbursable for VFC per PPACA/CMS and policy guidance
If required state modifier is omitted (e.g., SL, SE, EP), the serum and/or administration code may be denied per that state's rules
If units billed for administration exceed units billed for vaccine (or vice versa) without a matching corresponding unit, the excess units will be denied
Some state-specific product or program exclusions apply (e.g., CHIP products excluded from VFC in some states); verify state attachments for exclusions
SEPARATE VISIT PAYMENT: Separate payment for an office or well-child visit is allowed when documentation supports a separately identifiable visit and modifier 25 is appended to the visit code
Follow state guidance for appropriateness and documentation

Vaccine and Administration Codes

VFC administration CPT codesCPT

90460	Immunization administration (percutaneous, intradermal, subcutaneous, intramuscular) under VFC
90461	Immunization administration for each additional vaccine component (not reimbursable for VFC)
90471	Immunization administration, single vaccine
90472	Immunization administration, each additional vaccine (2nd or more)
90473	Immunization administration, intranasal or oral single
90474	Immunization administration, intranasal or oral each additional

VFC serum/toxoid codesmixed

Vaccine CPT/HCPCS codes

State-specific VFC serum/toxoid vaccine codes (see attachments/state lists)

Matching units requirement

Operational pairing requirementVaccine code(s) and administration code(s) may be submitted on separate claims but must be for the same date of service and billed by the same provider

Units must matchThe number of units billed for the vaccine and the administration must match; excessive units of either code will be denied (example: vaccine 90658 - 1 unit and administration 90472 - 2 units would result in denial)

Effect of mismatched unitsIf there is no corresponding vaccine code for an administration unit, the excess administration unit(s) will be denied

Claims pairing allowedVaccine serum/toxoid codes and administration codes may appear on separate claims provided date of service and provider match and units correspond

Submission and Billing Requirements for Providers

Billing Rule

VFC administration coding and submission — use 90460 or 90471-90474; 90461 not reimbursable

Submit vaccine administration using CPT 90460 or CPT 90471-90474 as directed by your State Fee for Service Medicaid Plan; do not report CPT 90461 for VFC services because PPACA/CMS rules specify 90461 is not reimbursable for VFC. Ensure administration codes used match the state-specific payable administration codes and follow state guidance for which administration codes are accepted.

Do not report CPT 90461 for VFC services; it is NOT reimbursable per PPACA/CMS.
Use 90460 or 90471-90474 only when those codes are payable in your state — check the State Fee for Service Medicaid Plan communications for which administration codes are payable.
When state guidance requires 90460 only (or a subset of codes), follow that state-specific instruction.

Key Terms and Modifiers

Children's Health Insurance Program (CHIP)

AcronymCHIP = Children’s Health Insurance Program

Relation to VFC policyListed under policy definitions and state exceptions as a distinct program that may have different applicability to VFC rules

State exceptions noteSome state programs (e.g., Cover Kids) are explicitly identified as exempt or treated separately from VFC in the State Exceptions section

Modifier SE

MeaningModifier SE indicates State or Federally Funded Program

Usage contextReferenced in the policy definitions and may be required by some states to be appended to serum and/or administration codes

State-specific requirementProviders should follow State Fee for Service Medicaid communications for modifier application details

Modifier SL

MeaningModifier SL indicates State Supplied vaccine

State examplesSeveral states require SL to be appended to serum and/or administration codes (policy cites Arizona, Missouri and other state exceptions)

Consequence of omissionMissing required SL modifier per state rules may cause claim denials; refer to the State Fee for Service Medicaid Plan for specific instructions

Vaccines for Children (VFC) program

Program establishedThe Vaccines for Children (VFC) program was established in 1993 to serve children defined as federally vaccine eligible under section 1928(b)(2)

Covered populationAll children from birth through 18 years of age (18 years + 364 days) who are covered by Medicaid are considered VFC eligible

Scope of vaccine inclusionImmunization programs receiving VFC funds must implement ACIP-recommended vaccines for which VFC resolutions and federal purchase contracts exist; ACIP lists 19 diseases covered by VFC vaccines

Combined antigen preferenceGenerally, combined antigen vaccines (e.g., MMR, DTaP) are provided through VFC; single antigen vaccines are available only when a combined antigen is contraindicated and documented