CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Childrens Care Services Payment Policy 12.03 V2

Defines billing, coverage inclusions, limitations, exclusions, documentation and coding guidance for pediatric services for Neighborhood Health Plan of Rhode Island across Medicaid (excluding EFP, RHP, RHE) and Commercial lines, and school-based health centers.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyChildrens Care Services Payment Policy 12.03 V2

Policy CodePolicy N/A

Change TypeTemporary addition: pediatric COVID vaccine counseling

Effective DateSep 1, 2010

Next Review Date

Key ActionVerify eligibility, coverage and authorization criteria prior to rendering services and ensure documentation supports billed services; bill pediatric COVID vaccine counseling same day as a scheduled preventive or sick visit with CPT 99401-99404 plus modifiers CR and 25 when applicable.

SourceLink

POLICY UPDATE CHANGES

Temporary Pediatric COVID Vaccine Counseling language added effective 2021-09-01

Policy review on 09/29/21 with no content changes

Format updates on 08/25/21

MultipleCPT/HCPCS codes listed

Medicaid, CommercialLines of business applicable

TemporaryCOVID counseling coverage status

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This policy is Neighborhood Health Plan of Rhode Island's Children's Care Services Payment Policy covering diagnosis, treatment and comprehensive pediatric services including routine office visits, preventive care, screenings, early intervention, fluoride varnish, ocular photoscreening and school-based services consistent with American Academy of Pediatrics guidance and Rhode Island law (RI Gen Laws § 27-38.1). It applies to Medicaid (excluding EFP, RHP, and RHE) and Commercial lines of business and includes guidance for school-based health centers to provide well and sick visits, immunizations, chronic care visits and physicals per regulatory requirements.

Scope includes prenatal pediatric office visit, pediatric preventative and routine visits, pediatric screenings, early intervention for qualified children up to age 3 years, pediatric development and autism screening, fluoride varnish (per age/frequency limits), and ocular photoscreening. Document history notes temporary pediatric COVID vaccine counseling added effective 2021-09-01 and prior review/format changes documented in the policy history.

Key facts / thresholds

Effective date2010-09-01

Last review2021-12-03

Policy statusCURRENT

Lines of businessMedicaid (excludes EFP/RHP/RHE), Commercial

Pediatric COVID counselingTemporary separate coverage — billed same day as preventive/sick visit with CPT 99401-99404 + modifiers CR and 25; member cost sharing waived

Coverage criteria and limits

General Reimbursement Prerequisites

All services must meet the following:

Medical necessity: Service is medically necessary
Reference sources for medical necessity: Neighborhood may use National Coverage Determination (NCD), Local Coverage Determination (LCD), InterQual, Rhode Island EOHHS recommendations, and Clinical Medical Policies to determine medical necessity
Eligibility verification: Provider must verify eligibility, coverage and authorization criteria prior to rendering services
Refer to Neighborhood's plan specific Prior Authorization Reference page and Clinical Medical Policies

Pediatric COVID Vaccine Counseling (temporary)

Covered when ALL of the following are met:

Same-day provision: Provided on the same day as a scheduled preventive or sick visit
Units per individual/family: May be billed once (1 unit) per individual member and/or once per family if more than one pediatric patient counseled at the same time1 unit per individual; may bill once per family
Required CPT codes: Must be billed with CPT code 99401, 99402, 99403, or 99404
Required modifiers: Must be billed with modifier CR and modifier 25
Cost sharing:

Coverage Limitations (age and frequency limits)

Services covered only within the specified limits:

Early Intervention services must be rendered by state certified providers for qualified members up to age 3 yearsup to age 3 years
Fluoride varnish limited to ages 6 months to 18.99 years; rendered by member's PCP or covering practitioner; annual limit of 4 units per calendar year6 months to 18.99 years; max 4 units/year
CRAFFT screening: CRAFFT Screening limited to 1 unit per calendar year for ages 11-21 years1 unit per calendar year; ages 11-21

Frequency & age thresholds

Fluoride varnishAges 6 months to 18.99 years; annual limit 4 units per calendar year

CRAFFT screening1 unit per calendar year for ages 11-21 years

Development/Autism screening (<3)Up to 5 services up to age 3 without authorization

Development/Autism screening (3-21)1 per year without authorization

Ocular photoscreeningCovered without authorization ages 6 months up to 5 years; age 5+ require authorization

Prenatal pediatric visitNo more than 2 visits; up to 30 minutes per visit

Codes and coding guidance

Listed covered CPT/HCPCS/T codes (general pediatric services)mixedCovered

99202	Office or other outpatient visit for the evaluation and management of a new patient, typically 20 minutes
99203	Office visit for new patient, typically 30 minutes
99204	Office visit for new patient, typically 45 minutes
99205	Office visit for new patient, typically 60 minutes
99211	Office or other outpatient visit for the evaluation and management of an established patient, usually minimal
99212	Office visit for established patient, straightforward medical decision making
99213	Office visit for established patient, low complexity
99214	Office visit for established patient, moderate complexity
99215	Office visit for established patient, high complexity
99381	Initial comprehensive preventive medicine evaluation and management of an individual; infant (new patient)

1–10 of 52

1/6

Excluded services for Medicaid membersmixedNot Covered

Exclusion

Routine dental care is not covered for Medicaid members; members born on or after 2000-05-01 who are RIte Care eligible should be referred to RIte Smiles program

Coding standards: The inclusion of a code in this policy does not guarantee coverage or reimbursement. Coding and billing must follow the American Medical Association's CPT codebook, the ICD-10-CM codebook, and the HCPCS Level II codebook. Providers must ensure appropriate code selection, use of modifiers, and documentation to support medical necessity and billed services.

Billing, documentation and authorization requirements

Billing Rule

COVID counseling modifiers and same-day billing

Pediatric COVID vaccine counseling must be provided on the same day as a scheduled preventive or sick visit to be separately reimbursable. Bill counseling once per member and/or once per family when multiple pediatric patients are counseled together. Use CPT codes 99401, 99402, 99403, or 99404 and append modifiers CR and 25 when billing. Member cost sharing for this counseling service is waived; cost sharing may still apply to the office visit code where applicable.

99401
99402
99403
99404
CR (modifier)
25 (modifier)
Family billing: may bill one unit for the family when multiple pediatric patients are counseled at the same time
Individual billing: may bill once (1 unit) per individual member

Billing Rule

Vision/hearing screening billing restriction

Vision and hearing screening (routine) are integral parts of the routine pediatric visit and are not separately billable when performed within that visit. Do not submit separate claims for these codes when reported as part of a standard preventive or sick visit.

99172
99173
92551
Not separately billable within routine pediatric visit

Documentation Required

Medical records on request

Neighborhood may request medical records to support billed services. Documentation must substantiate the services billed and demonstrate medical necessity in accordance with CMS standards for medical record documentation.

Neighborhood may request medical records for any service billed
Documentation must support billed services and medical necessity per CMS standards

Prior Authorization

Authorization verification

Verify member eligibility, benefits, and any required prior authorizations before providing services. Providers should consult Neighborhood's plan-specific Prior Authorization Reference page and Clinical Medical Policies for criteria and submission instructions.

Verify eligibility, coverage and authorization prior to rendering services
See Neighborhood's Prior Authorization Reference page and Clinical Medical Policies for plan-specific requirements

Billing Rule

Timely claim submission

Submit complete claims within the contractually determined timely filing guidelines. Ensure adjustments, corrections, and reconsiderations include required forms and comply with National Claims Standards. Claims must include appropriate coding and documentation to support payment.

Submit complete claims within timely filing guidelines specified in contract
Adjustments/corrections/reconsiderations must include required forms
All submissions must comply with National Claims Standards

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyChildrens Care Services Payment Policy 12.03 V2

Policy CodePolicy N/A

Change TypeTemporary addition: pediatric COVID vaccine counseling

Effective DateSep 1, 2010

Next Review Date

SourceLink

On This Page

OpenPayer

Childrens Care Services Payment Policy 12.03 V2

Policy summary and scope

Coverage criteria and limits

Codes and coding guidance

Billing, documentation and authorization requirements

Key definitions and acronyms

Document change log