CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Immunizations and Vaccine Administration Coverage

Defines Neighborhood Health Plan of Rhode Island coverage, limitations, billing and administration requirements for immunizations and vaccines for Medicaid, Integrity, and Commercial lines of business and affected providers.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyImmunizations and Vaccine Administration Coverage

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionVerify member eligibility, coverage and any required prior authorization before providing immunizations.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2Shingles vaccines allowed per lifetime

3HPV doses allowed per lifetime

15Maximum reimbursable administrations per day

State-suppliedVaccine cost borne by RI DOH

Coverage and Eligibility Rules

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Baseline coverage: Vaccine is listed on the RI DOH State Supplied Vaccine Schedule or is an additional immunization approved by Neighborhood aligned with its contract with the Department of Human Services

Chunks 0,3

Administration setting: Immunizations and vaccine administrations are generally covered when administered by the member's primary care provider (PCP) or covering practitioner; exceptions include Rabies, Diphtheria, Tetanus, Pertussis, COVID, and influenza which may be administered outside the PCP setting

Chunk 3

Medical necessity: All services must be medically necessary; Neighborhood may use National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs), InterQual, and RI EOHHS recommendations to determine medical necessity

Chunk 11

Vaccines and immunizations for travel are not covered. Although the policy lists certain travel vaccine CPT codes (for example: 90585, 90690, 90691, 90717, 90738) in the Coverage Includes section, these appear under a travel immunizations heading that conflicts with the stated exclusion. Providers should follow the exclusion that travel-related vaccines are not covered and verify coverage before billing when travel immunizations are being considered.

CPT/HCPCS Codes and Administration Limits

Covered vaccine CPT codes (listed in document)CPTCovered

90620	MENINGOCOCCAL (Serogroup B) 2 DOSE, IM
90621	MENINGOCOCCAL (Serogroup B) 3 DOSE, IM
90636	HEP A/HEP B VACCINE ADULT IM
90681	ROTAVIRUS LIVE, 2 DOSE ORAL
90710	MMRV LIVE, SUBCU
90713	POLIOVIRUS, INACTIVE, SUBCU OR IM
90733	MENINGOCOCCAL POLYSACCHARIDE, SEROGROUPS A,C,Y,W-135, QUAD, SUBCU
90736	ZOSTER (SHINGLES) LIVE, SUBCU
90740	HEP B VACC, ILL PAT 3 DOSE IM
90750	ZOSTER (shingles) VACC, IM

1–10 of 23

1/3

Administration codesCPT | HCPCSCovered

90460	Vaccine administration, counseling, first vaccine
90461	Vaccine administration, each additional vaccine
90471	Immunization administration (older CPT set) 1 injection
90472	Immunization administration: additional injections
90473	Immunization administration by intranasal/other route
90474	Immunization administration each additional intranasal/other
G0008	Administration of influenza virus vaccine
G0009	Administration of pneumococcal vaccine
G0010	Administration of hepatitis B vaccine

inv-07: Maximum administrations reimbursable per day

Maximum administrations reimbursable per day15

Shingles vaccine lifetime limit (related)2 per lifetime

HPV vaccine lifetime limit (related)3 per lifetime

Provider Responsibilities and Billing Guidance

Note

Prerequisites

All services must be medically necessary to qualify for reimbursement. Neighborhood may use the following sources to determine medical necessity: National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs), industry-accepted criteria such as InterQual, Rhode Island Executive Office of Health and Human Services (EOHHS) recommendations, and Neighborhood Clinical Medical Policies (CMP).

Prior Authorization

Verify eligibility / prior authorization

Providers must verify member eligibility, benefits, and any prior authorization requirements before rendering services. Refer to Neighborhood's plan-specific Prior Authorization Reference page and Clinical Medical Policies for details, and contact Provider Services at 1-800-963-1001 with questions.

Billing Rule

Claim submission requirements

Providers are required to submit complete claims in accordance with contractual timely filing limits and National Claims Standards. Claims must use coding that meets AMA CPT, ICD-10-CM, and HCPCS Level II standards.

Denial Risk

Claims missing vaccine code — denial risk

Vaccine product codes (NDC/HCPCS/CPT as applicable) must be billed along with the corresponding vaccine administration codes. Administration codes submitted without the matching vaccine code will be denied.

Affected codes: vaccine product codes and administration CPT/HCPCS codes

Documentation Required

Medical record support

Neighborhood reserves the right to request medical records for any billed service. Documentation must support the services billed and demonstrate medical necessity. Neighborhood follows CMS standards for proper medical record documentation.

Key Definitions

inv-13: Vaccines provided by the RI Department of Health

State-supplied vaccine costVaccines provided by the RI Department of Health are supplied at no cost to providers; Neighborhood does not reimburse the vaccine product

Administration reimbursementNeighborhood may reimburse the vaccine administration when applicable even though the vaccine product is state-supplied

EFP member coverage noteEFP Members are covered only for state-supplied vaccines and corresponding administrations; other vaccine/product charges are non-covered

Provider responsibilityProviders must verify eligibility and coverage; refer to plan-specific prior authorization references for details

Policy Background and References

This policy references the Rhode Island Department of Health State Supplied Vaccine program and aligns coverage with state-supplied vaccine availability. State-supplied vaccines are provided by the DOH at no cost to providers, and Neighborhood does not reimburse the vaccine product itself but does reimburse the vaccine administration when applicable. The policy also references national guidance sources (such as CDC recommendations) as the baseline for determining medically necessary immunizations and any additional vaccines approved under Neighborhood’s contract with the Department of Human Services.