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NC Medicaid Influenza Vaccine Guidelines for 2026-2027
NC Medicaid - NCDHHS·NC · Allergy & Immunology, Family Medicine, General Practice +2 more·Provider Bulletin
We identified it
Oct 13, 2026
Summary
NC Medicaid has released the 2026-2027 influenza vaccine guidelines specifying covered vaccine products, age restrictions, billing codes (CPT, ICD-10, NDC), and claim submission requirements for both Direct and Managed Care plans. Key billing requirement: all influenza vaccine and administration claims from pharmacies must append the CG modifier, and claims must include both vaccine and administration CPT codes to process. NDCs change annually and mismatched codes will deny with edit 00996.
Action Required
Billing team and pharmacy providers must immediately verify and update systems for the 2026-2027 influenza season: (1) Confirm correct 11-digit NDCs from the provided table are loaded in billing software to avoid claim denials with edit 00996 (Mismatched NDC); (2) Ensure all influenza vaccine CPT codes (90616, 90653, 90656, 90657, 90658, 90660, 90661, 90662, 90673) are paired with appropriate administration codes (90471, 90472, 90460, or 90473 based on age and route); (3) Append EP modifier to all administration codes for beneficiaries under age 21; (4) Pharmacy providers must append CG modifier to ALL influenza vaccine AND administration CPT codes on claims submitted through the immunization program; (5) Use ICD-10 diagnosis code Z23 on all medical claims; (6) For VFC-eligible children, bill vaccine CPT codes at $0.00 and request reimbursement only for administration fees; (7) Pharmacy providers must bill 11-digit NDCs and appropriate units per the Vaccine Point-of-Sale Catalogs and Rate Listings; (8) For NC Medicaid Managed Care beneficiaries, pharmacy providers should refer to individual health plan communications (Alliance Health, AmeriHealth Caritas, Carolina Complete Health, Healthy Blue, Trillium Health Resources, United Health Care, Vaya Partners) for plan-specific claim submission guidance. Failure to use correct NDCs and modifiers will result in claim denials requiring resubmission.