Immunizations

Updated: October 2026

Purpose

This policy defines immunization coverage and billing requirements for providers administering immunizations to ND Medicaid members. 

Applicability

Eligible Providers

To receive payment from ND Medicaid, the eligible servicing and billing providers must be enrolled with ND Medicaid on the date of service, and their National Provider Identifiers (NPIs) must be active in their Medicaid enrollment records. Servicing providers acting as a locum tenens provider must be enrolled with ND Medicaid, and services they provide must be billed with their NPI. Please refer to provider enrollment for additional details on enrollment eligibility and supporting documentation requirements.

This policy applies to ND Medicaid-enrolled providers administering immunizations to ND Medicaid members, including clinics, outpatient hospital facilities, pharmacies, Federally Qualified Health Centers (FQHCs), Rural Health Clinics (RHCs), and Tribal Health Partners. 

Eligible Members

Providers are responsible for verifying a member’s eligibility before providing services. Eligibility can be verified using the ND Medicaid MMIS Portal or through the Automated Voice Response System by dialing 1.877.328.7098.

Refer to the Member Eligibility Manual for additional information regarding eligibility including information regarding limited coverage categories. 

Covered Services and Limits

General Provider Policies

The General Provider Policies details basic coverage requirements for all services. Basic coverage requirements include:

• The provider must be enrolled in ND Medicaid;
• Services must be medically necessary;
• The member must be eligible on the date of service; and
• If applicable, the service has an approved service authorization. 

The Procedure Code Look-up Tool  can be used to identify if a procedure code is covered by ND Medicaid along with code specific details such as ORP requirements, Service Authorization requirements, and current rates. 

North Dakota Medicaid covers medically necessary immunizations for children and adults approved by the U.S. Food and Drug Administration (FDA). It also covers immunization administrations when another entity supplies the vaccine or toxoid. 

ND Medicaid uses the immunization schedules published by the Centers for Disease Control (CDC):

• Child and adolescent (18 years and younger)
• Adult (19 years and older)

Immunizations for Children

Vaccines for Children (VFC, state-supplied) immunizations, provided by the North Dakota Department of Health and Human Services (HHS), must be used when administering vaccines to members ages 0 through 18. 42 CFR Part 441 Subpart L. Providers administering immunizations to children in this age group must be enrolled in the HHS VFC program and receive the immunizations at no charge. 

The Immunization Coverage Table is updated annually and is available on the ND HHS Provider Immunization Unit Policies page. 

Immunizations for Adults

North Dakota Medicaid covers recommended immunizations for adults aged 19 and older. Coverage includes the vaccine and its administration. Recommended immunizations are those approved by the Food and Drug Administration (FDA) and recommended by the Advisory Committee on Immunization Practices (ACIP). Approved vaccines recommended by ACIP do not include vaccines the FDA has authorized but not approved under emergency use authorization.

ACIP Vaccine Recommendations and Guidelines can be found at

ACIP Vaccine Recommendations and Schedules | CDC.

Dual-eligible members with Medicare prescription drug plans (Medicare Part D) will have no out-of-pocket cost for adult vaccines recommended by the Advisory Committee on Immunization Practices (ACIP). For dual-eligible members, please refer to Medicare’s vaccine coverage found at Medicare Part D Vaccines.

Immunization Counseling

ND Medicaid covers stand-alone immunization counseling visits for all pediatric and adult immunizations, including the COVID-19 vaccine when provided by a physician or other qualified health care professional, including Local Public Health clinics. 

Members Under Age 21- HCPCS Codes

• G0312
  • Immunization counseling by a physician or other qualified health care professional when the vaccine(s) is not administered on the same date of service for ages under 21, 5 to 15 minutes. (This code is used for Medicaid billing purposes.)
• G0313
  • Immunization counseling by a physician or other qualified health care professional when the vaccine(s) is not administered on the same date of service for ages under 21, 16-30 minutes. (This code is used for Medicaid billing purposes.)
• G0314
  • Immunization counseling by a physician or other qualified health care professional for COVID-19, ages under 21, 16-30 mins time. (This code is used for the Medicaid Early and Periodic Screening, Diagnostic, and Treatment Benefit (EPSDT).
• G0315
  • Immunization counseling by a physician or other qualified health care professional for COVID-19, ages under 21, 5-15 mins time. (This code is used for the Medicaid Early and Periodic Screening, Diagnostic, and Treatment Benefit (EPSDT).

Members Age 21 and older – CPT® Codes

• 90482
  • Immunization counseling by physician or other qualified health care professional when immunization(s) is not administered by provider on the same date of service; 3 minutes up to 10 minutes
• 90483
  • Greater than 10 minutes and up to 20 minutes
• 90484 
  • Greater than 20 minutes

Immunization Administration

Please refer to the most recent version of the CPT® codebook for detailed instruction on reporting Immunization Administration for Vaccines/Toxoids.

• 90471
  • Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); 1 vaccine (single or combination vaccine/toxoid)
• 90472
  • Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); each additional vaccine (single or combination vaccine/toxoid) (List separately in addition to code for primary procedure)
• 90473
  • Immunization administration by intranasal or oral route; 1 vaccine (single or combination vaccine/toxoid)
• 90474
  • Immunization administration by intranasal or oral route; each additional vaccine (single or combination vaccine/toxoid) (List separately in addition to code for primary procedure)
• 90480
  • Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, single dose
• 96381
  • Administration of respiratory syncytial virus, monoclonal antibody, seasonal dose by intramuscular injection

Pediatric VFC Immunizations 

VFC Flu Vaccine for the 2026-2027 Flu Season

VFC COVID-19 Vaccine for the 2026-2027 Season

Non-VFC Pediatric Vaccines for the 2026-2027 Season

*Non-VFC COVID-19 vaccines are only payable to Medicaid-enrolled pharmacies that do not participate in the VFC Program.  This is available through December 2029 per the HHS Covid-19 PREP Act.

Adult Immunizations

Adult Flu Vaccines for the 2026-2027 Flu Season

Adult COVID-19 Vaccine

Limits

Vaccine counseling will not be reimbursed separately when provided with preventive medicine codes 99381-99397 or if the vaccine is administered on the same calendar date by the same service provider after the counseling is provided.   

The flu vaccine is limited to one vaccine per member per flu season (September – May).

Service Authorization Requirements

No service authorization required.

Noncovered Services

General Noncovered Services

The Noncovered Services Policy contains a general list of services that are not covered by North Dakota Medicaid. Non-covered immunizations include:

• Immunizations that are not FDA-approved; and
• Any Immunizations not listed in this policy.

Documentation Requirements

General Requirements

Providers must keep legible medical and financial records that fully justify and disclose the extent of services provided and billed to ND Medicaid. Records must be retained for at least 7 years after the last date the claim was paid or denied. Providers must follow the documentation requirements in the Provider Requirements Policy. 

Reimbursement Methodology and Claim Instructions

Timely Filing

ND Medicaid must receive an original Medicaid primary claim within one hundred eighty (180) days from the date of service. The time limit may be waived or extended by ND Medicaid in certain circumstances. The Timely Filing Policy contains additional information.

Third-Party Liability

Medicaid members may have one or more additional source of coverage for health services. ND Medicaid is generally the payer of last resort. Providers must pursue the availability of third-party payment sources. The Third Party Liability Policy contains additional information.

Client Share (Recipient Liability)

Client share (recipient liability) is the monthly amount a member must pay toward the cost of medical services before the Medicaid program will pay for services received. The Client Share Policy contains additional information. 

Reimbursement

A claim for services must be submitted at the provider’s usual and customary charge, excluding VFC-supplied vaccines, which must be billed at $0.00 or $0.01. Payment for services is limited to the lesser of the provider’s usual and customary charge or the ND Medicaid calculated reimbursement. 

Claim Form

VFC-supplied vaccines must be billed with modifier SL at $0.00 or a nominal fee of $0.01. 

All professional claims for vaccines must list the Ordering/Referring Provider. Please refer to the ORP Policy for complete details. 

Professional services billed electronically using the ASC X12N 837 transaction. Bill the immunization CPT® code and its corresponding administration code. Vaccines administered in a pharmacy must be submitted electronically using the ASC X12 837P transaction, not an NCPDP electronic pharmacy claim.

Institutional services billed electronically using the ASC X12N 837I transaction, the vaccine CPT® Codes must be billed using Revenue Code 0636. The administration CPT® codes must be billed using Revenue Code 0771. Both the immunization and administration must be billed on the same claim. 

A National Drug Code (NDC) submission is not required for vaccines. Submission of an NDC may result in claim line denial. 

FQHCs, RHCs, and Tribal Health Programs 

Immunization CPT® codes must be billed using Revenue Code 0636. The administration must be billed using Revenue Code 0771 with the appropriate CPT® code. Both the immunization and administration must be billed on the same claim. Immunizations are only separately reimbursed if no medical encounter was provided on the date of service. Please refer to the FQHC, RHCs, and Tribal Health Program policies for further information. 

References

• North Dakota Administrative Code
• North Dakota Century Code
• Code of Federal Regulations

Related Policies

• Ordering/Referring/Prescribing Providers

Frequently Asked Questions

Question (Q): Can immunizations or immunization administration be applied to Recipient Liability?  
Answer (A): Yes, both vaccines and their administrations can be applied to recipient liability.

Q: If multiple immunizations are administered, does 90472 have to be billed on separate lines? 
A: No, if multiple additional immunizations are administered, you can submit 90472 with the number of units of additional immunizations administered on a single claim line.  

Q: Can immunizations and their administration be billed on a pharmacy claim?
A: No, all immunizations must be billed through the medical benefit on either an 837P or 837I.  

Q: Do I need to submit an NDC on claims for immunizations?  
A: No, NDCs are not required for immunizations, and the submission may result in the denial of the claim line.

Contact

Medical Services
600 East Boulevard Ave 
Bismarck, ND 58505-0250
Phone: (701) 328-2310
Email: dhsmedicalservices@nd.gov

Policy Updates

October 2025

• VFC and Adult COVID-19 Vaccines
  • Updated NDCs for the 2025-2026 COVID-19 Season, added Nuvaxovid.