Neighborhood Health Plan RI Immunizations Coverage Update

Coverage Criteria

Covered when ALL of the following are met

Covered when ALL of the following are met:

General coverage: Immunizations and vaccinations for treatment of disease or prevention of infectious disease are covered; Neighborhood covers the RI Department of Health State Supplied Vaccine Schedule and additional vaccines approved by Neighborhood's Clinical Management Committee.

State-supplied vaccines cost: State-supplied vaccines provided by the RI Department of Health are available at no cost to providers; Neighborhood does not reimburse the vaccine product cost but does cover administration charges.

Influenza administration: Administration charges for all CDC‑approved influenza (flu) vaccines are covered regardless of whether the vaccine is state supplied; the vaccine product charge is not reimbursed.

Site of administration and exceptions: Immunizations and vaccine administrations are generally covered when provided by the member's primary care provider (PCP) or covering practitioner (PCP sites include physician offices, hospital outpatient departments, community health centers, and school‑based health centers); exceptions allowing administration outside the PCP include Flu, Rabies, Diphtheria, Tetanus, Pertussis, and COVID vaccines.

COVID‑19 vaccines and EUA: Coverage and reimbursement policy applies to FDA‑approved and CDC‑recommended COVID‑19 vaccines, including those authorized under Emergency Use Authorization, and applies during the Rhode Island COVID‑19 State of Emergency for vaccine product (as applicable) and administration.

Vaccines and immunizations administered solely for travel purposes are not covered. The policy explicitly excludes travel immunizations even though some travel vaccine CPT entries (for example, typhoid and yellow fever codes) appear in the code tables; inclusion in a table does not guarantee reimbursement. Providers should verify coverage prior to administration when travel-related vaccination is being considered.

Claims for vaccine administration require that the appropriate vaccine CPT/HCPCS code be billed on the same claim. Administration codes submitted without the corresponding vaccine code will be denied. Submit complete claims that include both the vaccine product code and the administration code within timely filing guidelines to avoid denials.

State-supplied vaccines provided by the Rhode Island Department of Health are available to providers at no cost. Because the vaccine product is state supplied, Neighborhood will not reimburse providers for the vaccine charge. Neighborhood will reimburse only for the vaccine administration when applicable (for example, administration charges for CDC-approved influenza vaccines remain covered regardless of state supply).

Coding and Billing Codes

Vaccine CPT Codes (general list)CPT

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	HEPB VACC, ILL PAT 3 DOSE IM
90750	ZOSTER (shingles) VACC, IM

1–10 of 12

1/2

Additional Vaccine CPT CodesCPT

90656	FLU VACCINE, TRI, PRSV FREE, 4 YEARS & >, IM
90662	FLU VACC,PRSV FREE INC ANTIG, IM
90689	FLU VACCINE, QUAD IIV4, IM
90670	PNEUMOCOCCAL VACC, PCV13, IM

Vaccine CPT/Q codes groupmixed

90732	PNEUMOCOCCAL POLYSACCHARIDE, 23 VALENT, ILL PAT, > 2 YEARS, SUBCU, IM
90733	MENINGOCOCCAL POLYSACCHARIDE, SUBCU
90736	ZOSTER VACC; SC
90740	HEP B, ILL PAT, 3 DOSE, IM
90750	ZOSTER (shingles) VACC, IM
Q2035	FLU VACCINE, SPLIT, 3 & >, IM (AFLURIA)

Travel Immunization CodesCPT

90585	Covered Travel Immunizations (All Ages)
90690	Typhoid vaccine, live, oral (Covered Travel Immunizations)
90691	90691 (listed as Covered Travel Immunizations)
90717	Yellow fever vaccine, live, for subcutaneous use
90738	90738 (listed as Covered Travel Immunizations)

COVID-19 vaccine and administration codesCPTCovered

91300	SARS-CoV-2 vaccine, mRNA-LNP, 30 mcg/0.3mL (Pfizer-BioNTech)
0001A	Immunization administration by intramuscular injection; first dose (Pfizer-BioNTech)
0002A	Immunization administration by intramuscular injection; second dose (Pfizer-BioNTech)
0003A	Immunization administration by intramuscular injection; third dose (Pfizer-BioNTech)
0004A	Immunization administration by intramuscular injection; Booster (Pfizer-BioNTech)
91307	SARS-CoV-2 vaccine, mRNA-LNP, 10 mcg/0.2 mL (Pfizer-BioNTech formulation)
0071A	Immunization administration by intramuscular injection; first dose (Pfizer 10 mcg)
0072A	Immunization administration by intramuscular injection; second dose (Pfizer 10 mcg)
91301	SARS-CoV-2 vaccine, mRNA-LNP, 100 mcg/0.5mL (Moderna)
0011A	Immunization administration by intramuscular injection; first dose (Moderna)

Pfizer COVID-19 vaccine and administrationmixedCovered

0001A	Immunization administration by intramuscular injection; first dose Pfizer-BioNTech COVID-19 First Dose (30 mcg/0.3 mL)
0002A	Immunization administration by intramuscular injection; second dose Pfizer-BioNTech COVID-19 Second Dose (30 mcg/0.3 mL)
0003A	Immunization administration by intramuscular injection; third dose Pfizer-BioNTech COVID-19 Third Dose (30 mcg/0.3 mL)
0004A	Immunization administration by intramuscular injection; Booster Pfizer-BioNTech COVID-19 Booster (30 mcg/0.3 mL)
91307	Pfizer-BioNTech COVID-19 Vaccine (10 mcg/0.2 mL) for intramuscular use
0071A	Immunization administration; first dose Pfizer-BioNTech (10 mcg/0.2 mL, tris-sucrose)
0072A	Immunization administration; second dose Pfizer-BioNTech (10 mcg/0.2 mL, tris-sucrose)

Moderna COVID-19 vaccine and administrationmixedCovered

91301	Moderna COVID-19 Vaccine (100 mcg/0.5 mL) for intramuscular use
0011A	Immunization administration by intramuscular injection; first dose Moderna COVID-19 First Dose (100 mcg/0.5 mL)
0012A	Immunization administration by intramuscular injection; second dose Moderna COVID-19 Second Dose (100 mcg/0.5 mL)
0013A	Immunization administration by intramuscular injection; third dose Moderna COVID-19 Third Dose (100 mcg/0.5 mL)
91306	Moderna COVID-19 Booster Vaccine (50 mcg/0.25 mL) for intramuscular use
0064A	Immunization administration; booster dose Moderna COVID-19 Booster Dose (50 mcg/0.25 mL)

Johnson & Johnson COVID-19 vaccine and administrationmixedCovered

91303	Johnson & Johnson COVID-19 Vaccine (Ad26 vector, 5x10^10 viral particles/0.5 mL) for intramuscular use
0031A	Immunization administration by intramuscular injection; single dose Johnson & Johnson COVID-19 Administration (5x10^10 viral particles/0.5 mL)
0034A	Immunization administration by intramuscular injection; booster dose Johnson & Johnson Booster Dose

Non-COVID related administration codesCPT|HCPCS

90460	Immunization administration through 18 years with counseling; first or only component
90461	Immunization administration through 18 years; each additional vaccine component
90471	Immunization administration; 1 vaccine (single or combination), includes injections
90472	Immunization administration; each additional vaccine (single or combination)
90473	Immunization administration by intranasal or oral route; 1 vaccine
90474	Immunization administration by intranasal or oral route; each additional vaccine
G0008	Administration of influenza virus vaccine
G0009	Administration of pneumococcal vaccine
G0010	Administration of hepatitis B vaccine

Maximum administrations per day

Maximum administrations reimbursable per dayUp to fifteen (15) administrations are reimbursable per day

Shingles lifetime limitShingles vaccines limited to two (2) per lifetime

HPV lifetime limitHPV limited to three (3) per lifetime

Provider Actions and Billing Requirements

Denial Risk

INTEGRITY billing requirement

Per Centers for Medicare & Medicaid Services (CMS), providers must bill Original Medicare for both the vaccine and the administration services for INTEGRITY members. Neighborhood will deny any claim for INTEGRITY members that is sent to Neighborhood; providers must submit those claims to Original Medicare.

Affected members: INTEGRITY (Original Medicare required)
Claims submitted to Neighborhood for INTEGRITY members will be denied

Documentation Required

Medical necessity determination

All services must be medically necessary to qualify for reimbursement. Neighborhood may use NCDs, LCDs, Interqual, RI EOHHS recommendations, and Neighborhood Clinical Medical Policies to determine medical necessity. Providers are responsible for verifying member eligibility, coverage, and any prior authorization requirements before rendering services.

Neighborhood may request supporting documentation to substantiate medical necessity

Background

Immunizations and vaccinations prevent infectious diseases and are provided according to the Rhode Island Department of Health state-supplied vaccine schedule. Neighborhood covers vaccines that align with the RI DOH schedule and additional vaccines approved by its Clinical Management Committee when medically necessary. State-supplied vaccines are provided at no cost to providers, and Neighborhood reimburses administration charges but not the vaccine product cost. Providers should consult the RI DOH and CDC websites for the current state-supplied and CDC-approved vaccine lists and ensure vaccines are administered in appropriate PCP or approved settings.

Definitions

State-supplied vaccines

State-supplied vaccines cost responsibilityState-supplied vaccines are provided by the Rhode Island Department of Health at no cost to providers; Neighborhood does not reimburse the vaccine product cost

Administration reimbursementNeighborhood covers administration charges for state-supplied vaccines (vaccine product not reimbursed)

CDC flu vaccine administrationAdministration charges for all CDC-approved influenza vaccines are covered regardless of whether the vaccine is state-supplied

Primary Care Provider (PCP) site

Definition of PCP site for immunizationsA Primary Care Provider (PCP) site may be a physician's office, a hospital outpatient department, or a community health center; school-based health centers are treated as PCP sites for immunization and vaccine administration

Coverage expectation

OpenPayer

Immunizations and Vaccines — Coverage and Reimbursement

Coverage Criteria

Coding and Billing Codes

Provider Actions and Billing Requirements

Background

Definitions