CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Coverage and Reimbursement Requirements for COVID-19 Vaccines and Administration

Governs Neighborhood Health Plan of Rhode Island's coverage and reimbursement requirements for FDA-approved and CDC-recommended COVID-19 vaccines and their administration across listed lines of business; affects in-network providers submitting claims to Neighborhood.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyCoverage and Reimbursement Requirements for COVID-19 Vaccines and Administration

Policy CodePolicy N/A

Change TypeAdded vaccine and administration codes

Effective DateDec 11, 2020

Next Review DateN/A

Key ActionBill identified administration CPT codes for vaccine administration; verify member eligibility and authorization criteria and retain documentation supporting medical necessity.

SourceLink

POLICY UPDATE CHANGES

Added new vaccine and administration codes 91303 and 0031A effective 2/27/21.

3COVID-19 vaccines listed

91300-91303Vaccine CPT codes

0001A-0031AAdministration CPT codes

WaivedMember cost share (Commercial)

Coverage criteria for COVID-19 vaccines and administration

Coverage for COVID-19 vaccines and administration

Covered when ALL of the following are met

Coverage conditions: 1) Vaccine is FDA-approved or CDC-recommended; EUA-authorized vaccines are included under this policy (examples: Pfizer-BioNTech, Moderna, Johnson & Johnson).

Applies during the Rhode Island COVID-19 State of Emergency as stated.

Administration coding: 2) Vaccine administration is billed using the identified administration CPT/HCPCS codes listed in this policy (administration codes for Pfizer, Moderna, and Johnson & Johnson as specified).

Providers must bill administration codes for separate reimbursement even when vaccine product is provided at no cost to providers.

Member cost share: 3) For Commercial plans, member cost sharing is waived for COVID-19 vaccine and administration when the vaccine is EUA-approved and CDC-recommended; providers must not collect cost share for the vaccine or administration, and no cost share should be applied to an office visit if the primary purpose is delivery of the recommended COVID-19 immunization.

Per CARES Act requirements.

Vaccine product reimbursement stance: 4) Vaccine product reimbursement is not provided to providers (vaccines are provided at no cost to providers through the federal government); providers should nevertheless bill vaccine CPT codes for data collection.

Applies to Medicaid and Commercial as stated.

Neighborhood will not reimburse providers for the COVID-19 vaccine product for Medicaid and Commercial lines because vaccines are being provided at no cost to providers through the federal government. Providers should nevertheless continue to bill the vaccine CPT/HCPCS product codes for data collection purposes as directed by Neighborhood. Vaccine administration codes are covered and will be reimbursed separately according to the administration codes listed in this policy.

For members enrolled in Medicare through Integrity (Original Medicare), providers must bill Original Medicare for both the vaccine product and the administration services for services provided in 2020 and 2021. Claims for Integrity members submitted to Neighborhood will be denied; providers should not bill Neighborhood for these members.

Neighborhood will not reimburse services that are determined to be not medically necessary. Medical necessity is assessed using Neighborhood's adopted references, including Local Coverage Determinations (LCDs), National Coverage Determinations (NCDs), industry-accepted criteria such as Interqual, EOHHS recommendations, and Neighborhood Clinical Medical Policies (CMPs).

Additionally, vaccine product reimbursement is not provided to providers when vaccines are supplied at no cost by the federal government; however, administration codes remain eligible for reimbursement and vaccine product codes should be billed for data collection only. Claims submitted for Integrity members to Neighborhood will be denied and must instead be billed to Original Medicare.

Covered CPT/HCPCS vaccine and administration codes

Covered CPT/HCPCS Vaccine and administration codes (Pfizer, Moderna)mixedCovered

91300	Pfizer-BioNTech COVID-19 Vaccine (30 mcg/0.3 mL)
0001A	Immunization administration — Pfizer-BioNTech COVID-19 First Dose
0002A	Immunization administration — Pfizer-BioNTech COVID-19 Second Dose
91301	Moderna COVID-19 Vaccine (100 mcg/0.5 mL)
0011A	Immunization administration — Moderna COVID-19 First Dose
0012A	Immunization administration — Moderna COVID-19 Second Dose

Covered CPT/HCPCS Vaccine and administration codes (Johnson & Johnson)mixedCovered

91303	Johnson & Johnson COVID-19 Vaccine (adenovirus type 26)
0031A	Immunization administration — Johnson & Johnson single dose

Provider responsibilities, billing and documentation

Prior Authorization

Medical necessity and prior authorization

All services must be medically necessary to qualify for reimbursement. Neighborhood may use the following to determine medical necessity: Local Coverage Determinations (LCDs), National Coverage Determinations (NCDs), industry-accepted criteria such as InterQual, EOHHS recommendations, and Neighborhood Clinical Medical Policies (CMPs). It is the provider's responsibility to verify member eligibility, coverage, and prior authorization requirements before rendering services. For plan-specific prior authorization information, refer to Neighborhood's Prior Authorization Reference page and Clinical Medical Policies. Contact Provider Services at 1-800-963-1001 with policy questions.

Local Coverage Determination (LCD)
National Coverage Determination (NCD)
InterQual and other industry-accepted criteria
EOHHS recommendations
Neighborhood Clinical Medical Policies (CMP)

Background and scope

This policy addresses COVID-19 vaccines that are FDA-approved or authorized and recommended by the CDC. Included product types are mRNA vaccines (Pfizer-BioNTech and Moderna) and adenovirus-vector vaccines (Johnson & Johnson). Coverage applies to vaccines approved or authorized under the FDA Emergency Use Authorization process, and to administrations given during the Rhode Island COVID-19 State of Emergency.

Per the policy, vaccine product codes may be billed for data collection even when the product is provided at no cost, while vaccine administration codes are covered and reimbursed separately as listed in the coding section.

Key definitions

FDA EUA vaccines

DefinitionVaccines approved through the FDA Emergency Use Authorization (EUA) process are included under this policy.

ScopeApplies to FDA‑approved and CDC‑recommended COVID‑19 vaccines and coverage of their administration during the Rhode Island COVID‑19 State of Emergency.

Examples of EUA/approved vaccinesPfizer‑BioNTech (2‑dose, approved 12/11/2020); Moderna (2‑dose, approved 12/19/2020); Johnson & Johnson (1‑dose, approved 2/27/2021).