CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Children's Care Services — Coverage Criteria

Defines coverage, limits, coding, and provider requirements for pediatric preventive, screening, and select intervention services for members classified as children under Neighborhood Health Plan of Rhode Island.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyChildren's Care Services — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization when services exceed stated age or frequency limits (for example, ocular photoscreening for age ≥5 or fluoride varnish beyond 4 units/year).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

age up to 18.99definition of child in claims system

4 units/yrFluoride varnish annual limit

≤5 servicesScreening limit (≤ age 3)

<5 no auth; ≥5 authOcular photoscreening auth rule

birth–age 3Early Intervention window

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Coverage Criteria — Children's Care Services

General coverage rules

Covered when delivered within age, provider, and frequency limits described below

General coverage

Provider constraints: Certain services must be rendered by the member's PCP or covering practitioner; Early Intervention services must be rendered by state-certified EI providers; school-based services are subject to regulatory age ranges and POS requirements (e.g., POS 03 for school).
Providers should document appropriate CPT/HCPCS/ICD codes and provider credentials as applicable

Episodes of care and settings: Episodes of care may occur across multiple settings including School (POS 03), Office (POS 11), Home (POS 12), Urgent Care Facility (POS 20), Outpatient (POS 22), and Federally Qualified Health Center (POS 50).

Prenatal pediatric visit limited to no more than 2 visits, up to 30 minutes each

Fluoride varnish

Fluoride varnish — covered when ALL of the following are met

Fluoride varnish criteria: Member age is between 6 months and 48 months; service is rendered by the member's PCP or covering practitioner; billed using HCPCS D1206 where applicable; limited to 4 units per calendar year.age 6 months–48 months; 4 units per calendar year

Services beyond these age or annual unit limits may require prior authorization and may be denied if billed without authorization

Development and autism screening

Pediatric development and autism screening — covered when ALL of the following are met

Development/autism screening criteria: Screening is administered in the PCP's office by the PCP or covering practitioner; billed using CPT 96110; up to 5 screening services are covered without authorization for members up to age 3; for members age 3 through 19, coverage without authorization is limited to one screening service per year.≤5 services up to age 3 without authorization; 1 per year for age 3–19 without authorization

Additional services beyond these limits may require prior authorization

Ocular photoscreening

Ocular photoscreening — covered when ALL of the following are met

Ocular photoscreening criteria: Member age ≥6 months and <5 years: ocular photoscreening (CPT 99174) is covered without prior authorization; member age ≥5 years: ocular photoscreening requires prior authorization before coverage.<5 years no authorization; ≥5 years requires authorization

CPT 99174

Early Intervention (EIP)

Early Intervention services — covered when ALL of the following are met

Early Intervention criteria: Member is qualified (experiencing developmental delays) and is under age 3; services are rendered by state-certified Early Intervention (EI) providers only; applicable Early Intervention CPT/HCPCS codes must be billed as listed (e.g., CPTs 92506, 92522, 92523, 92557, 96111; HCPCS H0046, H2000, etc.).birth to age 3

Payable only to state-certified EI providers; providers must document appropriate codes and credentials

School-based health centers

School-based health center services — covered when ALL of the following are met

School-based health centers: Services are provided to members greater than 11 and up to age 21 as appropriate to the school-based setting; covered services may include well and sick visits, immunizations, chronic care visits (e.g., asthma, diabetes), and physicals; billed with appropriate CPTs for school-based settings (e.g., CPTs 99201–99215, 99383–99385) and POS 03 where applicable.age >11 and <21

Subject to regulatory requirements and plan documentation rules

These Children's Care Services do not apply to members who are outside the program eligibility described in the plan. Specifically, Rhody Health Plan (RHP) members (age 21 and older) and Extended Family Planning (EFP) members are excluded because EFP members do not have a comprehensive benefit package. Routine dental care is also not covered under this benefit; for RIte Care-eligible children born on or after May 1, 2000, refer to the RIte Smiles program for dental coverage.

Per Rhode Island EPSDT guidance, vision screening (CPT 99172, 99173) and hearing screening (CPT 92551) are considered part of the annual pediatric visit and follow the EPSDT schedule. As such, these screenings are not separately billable under Children’s Care Services when performed as part of the annual pediatric visit.

Coding — CPT / HCPCS / ICD Lists and Limits

Covered CPT/HCPCS/ICD-9 for prenatal, preventative care, fluoridemixedCovered

V65.11	ICD-9 diagnosis for Prenatal Pediatrician Office Visit
99201	Prenatal Pediatrician Office Visit CPT range start
99203	Prenatal Pediatrician Office Visit CPT range end
99241	Prenatal Pediatrician Office Visit CPT range start
99242	Prenatal Pediatrician Office Visit CPT range end
V20.1	ICD-9 diagnosis for Pediatric Preventative Care
V21.35	ICD-9 diagnosis range included in Pediatric Preventative Care
99381	Pediatric Preventative Care CPT range start
99385	Pediatric Preventative Care CPT range end
99391	Pediatric Preventative Care CPT range start (younger age)

1–10 of 14

1/2

Covered Early Intervention CPT/HCPCSmixedCovered

92506	Early Intervention CPT
92522	Early Intervention CPT
92523	Early Intervention CPT
92557	Early Intervention CPT
96111	Early Intervention CPT
97001	Early Intervention CPT
97003	Early Intervention CPT
99205	Early Intervention CPT (office visit)
H0046	Early Intervention HCPCS
H2000	Early Intervention HCPCS

1–10 of 20

1/2

Screening CPT codesCPTCovered

96110	Pediatric Development and Autism Screening CPT
99174	Ocular Photoscreening CPT

School Based Health Center CPTsCPTCovered

99201	School Based Health Centers CPT range start
99215	School Based Health Centers CPT range end
99383	School Based Health Centers preventive CPT range start
99385	School Based Health Centers preventive CPT range end

Fluoride varnish annual units

Annual limit4 units per calendar year

Member age restrictionService limited to members age 6 months to 48 months

Provider requirementRendered by the member's PCP or covering practitioner

Pediatric development/autism screening frequency limits

Under age 3Up to 5 screening services without prior authorization (administered in PCP office)

Age 3–19Limited to one screening service per year without prior authorization

Provider Actions — Authorization, Documentation, and Limits

Prior Authorization

Fluoride Varnish Limits and Authorization

Fluoride varnish is limited to members aged 6 months through 48 months and must be rendered by the member's PCP or covering practitioner. There is an annual limit of 4 units per calendar year. Services beyond these age or unit limits may require prior authorization and are at risk for denial if billed without authorization.

Age eligibility: 6 months to 48 months (inclusive).
Annual unit limit: 4 units per calendar year.
Billing note: HCPCS D1206.

Denial Risk

Age / Volume Limits May Trigger Authorization or Denial

Age and volume limits for specific pediatric services may trigger a requirement for prior authorization; services provided beyond the stated age ranges or number-of-service limits are at risk for denial if not authorized. Verify member age, service counts, and obtain authorization when limits are exceeded.

Background

Children's Care Services cover a set of preventive and screening services for plan-defined children, but exclude members and services outside that scope. Note that exclusions include older adult RHP members and EFP members without comprehensive benefits, and routine dental care is handled through other programs (for example, RIte Smiles for eligible children).

Definitions

Child — claims system definition

Plan claims system definitionChild = member up to age 18.99

RI DOH alignment noteDefinition aligns with RI DOH State Supplied Vaccine Program mention in policy

Scope implicationApplies to coverage rules for preventive, screening, and early intervention services

Early Intervention (EI) — provider and age requirements

Provider qualificationEarly Intervention services payable only to state‑certified EI providers

Age windowFor qualified children from birth up to age 3 years

Clinical requirement