Neighborhood Health Plan RI pediatric services Coverage

Coverage Criteria

Covered Services and Limits

Covered when services are medically necessary and meet applicable program rules and provider qualifications:

General coverage prerequisites: Services must be medically necessary and may be determined using NCDs, LCDs, InterQual, EOHHS recommendations, and Neighborhood Clinical Medical Policies; providers must verify member eligibility and any required authorizations prior to rendering services.

Referenced in prerequisites section

Types of covered pediatric services: Includes prenatal pediatric office visit; pediatric preventive care visits (well-child, routine, sick); pediatric screenings (developmental, autism, CRAFFT substance-use screening); fluoride varnish; early intervention services for qualified children birth to age 3; ocular photoscreening; school-based health center services as appropriate.

Listed under Coverage Includes

Service-specific limits: Early Intervention services must be rendered by state certified providers up to age 3; fluoride varnish limited to ages 6 months through 18.99 years with an annual limit of 4 units and must be rendered by the member's PCP or covering practitioner; CRAFFT screening limited to 1 unit per calendar year for ages 11-21; pediatric development and autism screening limited to up to 5 services through age 3 and to 1 per year for ages 3-21, rendered by the member's PCP or covering practitioner; ocular photoscreening is allowed without authorization for ages 6 months up to 5 years and requires authorization for age 5 and older; prenatal pediatric visit limited to no more than 2 visits up to 30 minutes each; pediatric COVID counseling limited to members up to and including age 21.

Coverage Limitations section

Specific screening and fluoride varnish billing criteria

Covered when billed with the specified diagnosis code(s) AND corresponding procedure code(s):

Pediatric Developmental Screening: Service is billed with diagnosis Z00.121 or Z00.129 AND a code from Table 3 (96110).

Table 3 lists 96110

Pediatric Autism Screening: Service is billed with diagnosis Z00.121 or Z00.129 AND a code from Table 3 (96110) with modifier U1.

Modifier U1 required for autism screening

Pediatric Fluoride Varnish: Service is billed with diagnosis Z29.3 AND a code from Table 4 (99188 or D1206).

Table 4 lists 99188 and D1206

Routine dental care is not covered for Medicaid members; refer eligible children born on or after May 1, 2000 to the RIte Smiles program as applicable. Vision screening (CPT 99172, 99173) and hearing screening (CPT 92551) are considered part of the routine pediatric visit and are not separately billable.

This policy is informational and does not guarantee reimbursement. Claim payments are subject to plan benefit coverage, member eligibility, claims payment edit rules, coding and documentation guidelines, authorization policies, provider contract agreements, and applicable state and federal regulations. Providers are responsible for verifying eligibility, coverage and authorization criteria prior to rendering services.

All services must be medically necessary to qualify for reimbursement. Neighborhood may determine medical necessity using National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs), industry-accepted criteria such as InterQual, Rhode Island EOHHS recommendations, and Neighborhood Clinical Medical Policies; services that do not meet those standards may be denied as not medically necessary.

Coding and Billing

Selected covered procedure codes (part 1)CPTCovered

92522	Evaluation of speech sound production (eg, articulation, phonological process, apraxia, dysarthria)
92523	Evaluation of speech sound production; with evaluation of language comprehension and expression (eg, receptive and expressive language)
92557	Comprehensive audiometry threshold evaluation and speech recognition (92553 and 92556 combined)
96112	Developmental test administration ... first hour
96113	Developmental test administration ... each additional 30 minutes
97161	Physical therapy evaluation: low complexity; typically 20 minutes
97162	Physical therapy evaluation: low complexity; typically 20 minutes

Selected covered procedure codes (part 2)CPTCovered

97163	Physical therapy evaluation: high complexity; typically 45 minutes
97164	Re-evaluation of physical therapy established plan of care; typically 20 minutes
97165	Occupational therapy evaluation, low complexity; typically 30 minutes
97166	Occupational therapy evaluation, moderate complexity; typically 45 minutes
97167	Occupational therapy evaluation, high complexity; typically 60 minutes
97168	Re-evaluation of occupational therapy established plan of care; typically 30 minutes
99174	Instrument-based ocular screening (eg, photoscreening, automated-refraction), bilateral; with remote analysis and report
99177	Instrument-based ocular screening (eg, photoscreening, automated-refraction), bilateral; with on-site analysis
99202	Office or other outpatient visit for a new patient; 15-29 minutes
99203	Office or other outpatient visit for a new patient; 30-44 minutes

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Not separately billable within routine pediatric visitCPTNot Covered

99172	Vision screening — part of routine pediatric visit; not separately billable
99173	Vision screening — part of routine pediatric visit; not separately billable
92551	Hearing screening — part of routine pediatric visit; not separately billable

Preventive and E/M CPT CodesCPTCovered

99211	Office or other outpatient visit for the evaluation and management of an established patient, minimal presenting problems
99212	Office/outpatient visit for established patient; medically appropriate history/exam and straightforward decision making; 10-19 minutes
99213	Office/outpatient visit for established patient; medically appropriate history/exam and low level decision making; 20-29 minutes
99214	Office/outpatient visit for established patient; moderate level medical decision making; 30-39 minutes
99215	Office/outpatient visit for established patient; high level medical decision making; 40-54 minutes
99381	Initial comprehensive preventive medicine E/M, new patient; infant (<1 year)
99382	Initial comprehensive preventive medicine E/M, new patient; early childhood (1-4 years)
99383	Initial comprehensive preventive medicine E/M, new patient; late childhood (5-11 years)
99384	Initial comprehensive preventive medicine E/M, new patient; adolescent (12-17 years)
99385	Initial comprehensive preventive medicine E/M, new patient; 18-39 years

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Other service HCPCS/T codesHCPCS

H0046	Mental health services, not otherwise specified
H2000	Comprehensive multidisciplinary evaluation
S0302	Completed EPSDT service (list in addition to code for appropriate E/M service)
S9446	Patient education, not otherwise classified, nonphysician provider, group, per session
T1013	Sign language or oral interpretive services, per 15 minutes
T1016	Case management, each 15 minutes
T1022	Contracted home health agency services, per day
T1023	Screening for program/treatment appropriateness, per encounter
T1024	Evaluation and treatment by integrated specialty team, per encounter
T1027	Family training and counseling for child development, per 15 minutes

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COVID vaccine counseling codesCPTCovered

99401	Preventive medicine counseling/risk factor reduction; ~15 minutes (COVID vaccine counseling when billed with CR and 25 modifier)
99402	Preventive medicine counseling/risk factor reduction; ~30 minutes
99403	Preventive medicine counseling/risk factor reduction; ~45 minutes
99404	Preventive medicine counseling/risk factor reduction; ~60 minutes

Pediatric developmental/autism screening codes (Table 3)CPTCovered

96110

Developmental screening with scoring and documentation, per standardized instrument

Pediatric fluoride varnish codes (Table 4)CPT | HCPCSCovered

99188	Application of topical fluoride varnish by a physician or other qualified health care professional
D1206	Topical fluoride varnish; therapeutic application for moderate to high caries risk patients

Fluoride varnish age range

Age range6 months to 18.99 years

Annual limit4 units per calendar year

ProviderRendered by the member's PCP or covering practitioner

CRAFFT screening frequency and age

Applicable agesAges 11-21 years

Frequency limit

Provider Actions and Billing Requirements

Prior Authorization

Prior Authorization Required for Ocular Photoscreening (age ≥5)

Ocular photoscreening for members age 5 years and older requires prior authorization; ocular photoscreening for members age 6 months through 5 years does not require authorization.

Ocular photoscreening: Ages 6 months up to 5 years — no authorization required.
Ocular photoscreening: Age 5 years and older — prior authorization required.

Denial Risk

Medical Necessity Requirements and Denial Triggers

All services must meet medical necessity criteria to qualify for reimbursement. Neighborhood may apply NCDs, LCDs, industry-accepted criteria (e.g., InterQual), EOHHS recommendations, and Neighborhood Clinical Medical Policies when determining medical necessity. Non-medically necessary services may be denied.

Background

This policy addresses routine pediatric preventive care and related services including well-child and routine visits, developmental and autism screening, ocular photoscreening, application of topical fluoride varnish, and Early Intervention (EI) services for eligible children. EI services must be provided by state-certified providers for qualified children through age 3 years. The policy also documents billing and service limits (for example, fluoride varnish age range and annual limits, screening frequency limits), coding requirements, and recent document history changes such as the addition of specific tables for developmental/autism screening and fluoride varnish.

Definitions

Early Intervention (EI) services

DefinitionServices rendered by state certified providers for qualified children from birth up to age 3 years who are experiencing developmental delays.

Age rangeBirth through age 3 years

Provider typeState certified Early Intervention (EI) providers

Pediatric COVID vaccine counseling

When billableCounseling must be provided on the same day as a scheduled preventive or sick visit

FrequencyMay be billed once (1 unit) per individual member

Billing codes and modifiers

OpenPayer

Children's Care Services (Pediatric Preventive and Related Services)

Coverage Criteria

Coding and Billing

Provider Actions and Billing Requirements

Background

Definitions