Medical, Dental & Pharmacy

Immunizations & Vaccinations

Overview

Vaccination is a covered health care service for Minnesotans enrolled in PrimeWest Health or any other publicly funded Minnesota Health Care Programs (MHCP).

Minnesota Vaccines for Children (MnVFC)

The Minnesota Department of Human Services (DHS) works with the Minnesota Department of Health (MDH) to administer the MnVFC program, which provides pediatric vaccines and some adult vaccines to PrimeWest Health members.

For more information about MnVFC, please visit the MnVFC program website. The MnVFC program is an expanded version of the national Vaccines for Children (VFC) program that uses Federal funding to provide increased vaccine coverage to Minnesotans. The program supplies vaccine at no cost to participating providers. These vaccines meet the recommendations of the Advisory Committee on Immunization Practices (ACIP) and are approved by the Centers for Disease Control and Prevention (CDC). Before purchasing a vaccine for child members ages 0 – 18, providers must first attempt to obtain the vaccine from MnVFC.

The MnVFC program caps the administration fee you may charge per dose (not per vaccine antigen). See the Minnesota Department of Health's (MDH) Immunization Billing Guidance for MnVFC for more information.

Eligible Providers

The following PrimeWest Health-enrolled health care providers may bill for vaccines:

  1. Certified family nurse practitioners
  2. Certified pediatric nurse practitioners (NPs)
  3. Certified nurse midwives (CNMs)
  4. Child and Teen Checkup (C&TC) providers
  5. Clinics
  6. Community paramedics
  7. Convenience clinics
  8. Home health agencies
  9. Outpatient and inpatient hospitals
  10. Pharmacies
  11. Physicians
  12. Public Health clinics
  13. Public Health nursing clinic providers

All PrimeWest Health-enrolled providers who administer pediatric vaccines are required by State law (MN Stat. sec. 256B.0625, subd. 39), to be enrolled in the MnVFC program or provide stock vaccines at no charge to Medical Assistance members.

Eligible Members

Infants, children, and some adults enrolled in PrimeWest Health are eligible to receive vaccines through the MnVFC program. Refer to the Benefits section for coverage determination.

PrimeWest Health Vaccines and Toxoids Quick Reference

Age groups listed under PrimeWest Health coverage do not indicate guidelines for administration of the vaccine or the availability of the vaccine through MnVFC for the age groups listed.

Refer to the CDC VFC Vaccine Resolutions for more information about eligible age groups, recommended vaccine schedules, and recommended dosage information for specific vaccines. For PrimeWest Health-enrolled adults age 19 and over, non-MnVFC covered vaccines must be administered with stock vaccines and are covered by PrimeWest Health.

Vaccines listed as unavailable through MnVFC are covered by PrimeWest Health. Use the appropriate CPT codes listed in the table below when billing PrimeWest Health for vaccines. For more information, review the Immunizations and Vaccinations section of the MHCP Provider Manual. 

PrimeWest Health does not cover tetanus and diphtheria toxoids, vaccine code 90718. Use the preservative-free tetanus and diphtheria toxoids vaccine code 90714 for both preservative and preservative-free vaccine billing.

Refer to the Immunization and Vaccine Benefits Codes for Children section of the DHS Provider Manual for a complete list of codes allowed by age.

Vaccine Administration Codes

CPT Code

Description

90460

Immunization administration through age 18 via any route of administration, with counseling by physician or other qualified health care profession; first vaccine/toxoid component. Do not use with 90571 or 90473.

90461

Use only with 90460 (when performing physician/health care professional counseling). 90461 must be used with 90460 if two or more vaccines are administered.

90471

Administration of the first or a single vaccine (percutaneous, intradermal, subcutaneous, or intramuscular injections) on a single date of service (DOS). (Do not report 90471 in conjunction with 90473.)

90473

Administration of the first or a single vaccine (oral or intranasal routes of administration) on a single (DOS). (Do not report 90473 in conjunction with 90471.)

90474

Administration of each additional vaccine (oral or intranasal routes of administration) on a single DOS. (List separately in addition to code for primary procedure.)
90480 Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (sars-cov2) (coronavirus disease [covid-19]) vaccine, single dose, includes counseling
96380 Administration of respiratory syncytial virus, monoclonal antibody, seasonal dose by intramuscular injection, with counseling by physician or other qualified health care professional
96381 Respiratory syncytial virus, monoclonal antibody, seasonal dose; 1 ml dosage, for intramuscular use

G0008

Administration of influenza virus vaccine

G0009

Administration of pneumococcal vaccine

G0010

Administration of hepatitis B vaccine (HepB)

The CDC considers the VFC administration reimbursement amount to be paid on a per injection basis, not a per component basis.

Providers must bill according to the following instructions:

  1. All providers submitting charges must bill for vaccines using CPT codes
  2. Bill the vaccine administration code in addition to the vaccine code
  3. Use the modifier SL with the vaccine CPT code when billing for administration of vaccines from the MnVFC program
  4. When billing for the administration of MnVFC vaccines, continue to enter the price of the vaccine at $0.00 and use the appropriate administration code. The administration and vaccine must be billed on the same claim.
  5. When billing for stock vaccines for non-covered MnVFC vaccines for PrimeWest Health members, PrimeWest Health pays the vaccine fee schedule rate plus the prevailing fee schedule rate for the non-MnVFC administration fee. Bill the appropriate administration and vaccine codes; do not use the SL modifier.

Claims will be denied if any of the following occurs:

  1. A vaccine is billed without a vaccine administration code indicating the administration of the initial injection
  2. Administration codes are billed without vaccine CPT codes
  3. Vaccine and administration codes are not billed on the same claim.

In addition to the CPT vaccine codes, usual and customary (U&C) charges for an office visit associated with the vaccination may also be billed. Office visit charges should not be billed if the appointment is solely to administer vaccine(s).

When billing for influenza vaccines, please note the following:

  1. Bill preservative-free and preservative-containing influenza vaccines using different vaccine codes, even if they are indicated for the same age group
  2. Bill the vaccine’s administration code in addition to the vaccine code. When giving MnVFC vaccines, bill the code for the vaccine with modifier SL. PrimeWest Health will reimburse providers the prevailing fee schedule rate for the administration fee for each single or combination MnVFC vaccine administered.
  3. For members age 19 and over, PrimeWest Health pays the vaccine fee schedule rate plus the prevailing fee schedule rate for the non-MnVFC administration fee. Bill the appropriate administration and vaccine codes; do not use the SL modifier.

Providers must obtain the available vaccines for MnVFC-eligible members from MDH. The program supplies vaccine at no cost to participating providers. PrimeWest Health will reimburse providers only for the administration of MnVFC vaccines. Please note the following:

  1. Federal legislation limits the amount a MnVFC participating provider may charge for administering a vaccine to a MnVFC child
  2. PrimeWest Health will reimburse providers the prevailing fee schedule rate for the administration fee for each single or combination MnVFC vaccine administered
  3. PrimeWest Health does not pay for purchase of vaccines available through MnVFC

Adult Immunizations

MDH does not provide free vaccines for adults age 19 or over through the MHCP Adult Vaccine Program. Providers will need to purchase doses of vaccine for adults and bill PrimeWest Health for the vaccine and vaccine administration. MDH will continue to provide vaccines for children from birth through age 18.

Refer to the MHCP Immunization and Vaccine Benefit Codes for Adults section of the DHS Provider Manual for a complete list of billing codes to use when billing for vaccines provided to adults.

Vaccines Covered by Medicare Part D
PrimeWest Health members covered under PrimeWest Senior Health Complete (HMO SNP) and PrimeWest Health Complete (HMO SNP) receiving Medicare Part D-eligible vaccinations must have both the vaccine and its administration billed through the member’s Part D benefit. Claims for vaccines classified as Part D-eligible cannot be reimbursed through PrimeWest Health’s medical administration. They must go through the pharmacy benefit in accordance with Part D regulations. Part D-eligible vaccines include, but are not limited to, the following vaccines:

  1. Gardasil
  2. MMR
  3. Comvax
  4. Shingrix
  5. Tice BCG
  6. Diphtheria/tetanus toxoid
  7. ActHIB
  8. Menactra
  9. Tetanus toxoid
  10. RabAvert
  11. Twinrix
  12. Energix-B
  13. Zostavax
  14. Arexvy and Abrysvo

PrimeWest Health provides an online option for processing Medicare Part D-eligible claims. TransactRx Vaccine Manager, a product of POC Network Technologies (PNT), is a web portal that offers providers real-time claims processing for office-administered vaccines. Enrollment information and instructions are available online.

Providers filing a Medicare Part D vaccine and administration claim must accept PrimeWest Health’s reimbursement amount (including member’s copay) as payment in full for the vaccine.

 

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Updated_03/16/2026