Provider Notice issued 06/15/07

Reimbursement for Human Papillomavirus (HPV) Vaccine and Enrollment in the Vaccines for Children (VFC) Program

The purpose of this notice is to provide information on the department’s reimbursement for the new Human Papillomavirus (HPV) vaccine [Gardasil®] and to encourage providers to enroll in the Vaccines for Children (VFC) Program. 

Reimbursement for HPV Vaccine 

Effective January 1, 2007, the FDA-approved HPV vaccine, Gardasil®, was added to the VFC Program. Providers participating in the VFC Program are eligible for an administration fee of $6.40 for each of the three vaccinations in the Gardasil® series administered to females 9 through 20 years of age. VFC participating providers should use CPT code 90649 when billing for the administration of Gardasil®.

Providers who do not routinely administer vaccinations, such as those in obstetrics and gynecology practices, and are, therefore, not enrolled in the VFC Program, may bill for the Gardasil® vaccine provided to patients 9 through 20 years of age by using CPT 90649 with the modifier SL. Using the SL modifier will indicate that the provider is being reimbursed by the state for the vaccine. These services will be paid at a maximum rate of $149.33 for each vaccine in the 3 dose series.

For females ages 21 through 26, all providers are eligible for a maximum rate of $149.33 for each vaccination in the 3 dose series. These services should be billed using CPT code 90649 with the modifier SL.

Providers not enrolled in the VFC Program, who received the $6.40 administration reimbursement rate for the cost of the Gardasil® vaccine since January 1st, may submit an adjustment form to the department to void the previously paid service, in order to rebill for the cost of the vaccine. Instructions for completing an adjustment form are in Chapter 100, General Appendix 6, located on the department’s Web site at: <http://www.hfs.illinois.gov/handbooks/chapter100.html>.

After the adjustment is processed, the provider can then rebill the service and the department will reimburse the vaccine at the provider’s charge or up to the department’s maximum rate of $149.33 per injection. When rebilling, providers must use modifier SL with procedure code 90649 on both paper and electronic claims in order for the service to pay correctly at the higher rate.

VFC Enrollment 

The Illinois Department of Public Health (IDPH) and Chicago Department of Public Health (for Chicago) administer the VFC Program, which is a federally funded program that provides free vaccines to providers for eligible participants. All HFS-enrolled children through age 20 are covered for vaccines, either through the VFC Program or an interagency agreement between HFS and IDPH to provide the vaccines. By participating in the VFC Program, providers are saved out-of-pocket expense for the purchase of the vaccines they use in their practice.

The department will not mandate enrollment in the VFC Program in order for providers to administer the Gardasil® vaccine for patients ages nine through 20. Providers who choose not to enroll will be reimbursed for Gardasil® up to the state maximum of $149.33 when the SL modifier is billed. However, the department strongly encourages OB/GYN providers, and any other providers who do not currently participate in the VFC Program, to enroll. By enrolling in the VFC Program, a provider is not required to administer other childhood vaccines, but is encouraged to do so, if a patient under age 21 needs a particular childhood vaccine.

Providers, located outside of Chicago, may contact the Vaccines for Children Program at 800-526-4372 or 217-785-1455 for an enrollment packet. Providers located in Chicago should contact the Chicago VFC Program at 312-746-6358.

Any questions regarding this notice may be directed to the Bureau of Comprehensive Health Services at 877-782-5565.

Theresa A. Eagleson, Administrator
Division of Medical Programs