MedicaidBilling CodesHigh impact
ForwardHealth Vaccine Coverage: New Sources of Vaccine Recommendations and Revised Billing for COVID-19, Influenza, and Measles, Mumps, Rubella, and Varicella VaccinesDecember 2, 2025: This Update has been revised since its original publication. Revised information appears in red text on page 3.
Wisconsin Medicaid (ForwardHealth)·WI · Pediatrics, Family Medicine, Internal Medicine +3 more·Billing
Effective date
Nov 1, 2025
We identified it
Sep 29, 2026
Summary
ForwardHealth is expanding vaccine coverage sources beyond ACIP recommendations to include vaccines from evidence-based bodies like AAP and National Academy of Medicine, and implementing new billing processes for COVID-19, influenza, and MMRV vaccines effective November 1, 2025. Claims submitted October 1-31, 2025 will be suspended and automatically processed November 1. Providers must now submit specific vaccine product codes with SL modifier for VFC-supplied vaccines and administration codes for these three vaccine types.
Action Required
By October 31, 2025: Billing team must update billing system to handle claims suspension for COVID-19, influenza, and MMRV vaccines submitted October 1-31. By November 1, 2025: Update billing software to require specific vaccine product codes (91304, 91319, 91320, 91321, 91322, 91323) AND administration code 90480 on the same claim for COVID-19 vaccines. For VFC-eligible members under age 19, add SL modifier (state-supplied vaccine) to vaccine product codes but NOT to administration codes. For all three vaccine types (COVID-19, influenza, MMRV), ensure system submits both vaccine and administration codes together. Providers must document in member records when VFC vaccine is unavailable and private stock is used, including clinical rationale. Train billing and clinical staff on new modifiers and code combinations. Update claim templates and encounter forms to prompt for both vaccine product and administration codes. Verify max allowable fee schedules on ForwardHealth Portal are current. Resubmit any improperly coded claims from October 1-31 suspension period to ensure reimbursement.