Neighborhood Health Plan RI pediatric policy update

Coverage Criteria and Limits

inv-01: Covered Services — Covered pediatric services include the following categories

Covered pediatric services include the following categories

Covered Services List: Prenatal pediatric office visit; pediatric preventive care visits (well-child, routine, sick); pediatric screenings; fluoride varnish; early intervention services for qualified children birth to age 3; pediatric development and autism screening; ocular photoscreening.

Coverage aligns with AAP guidance and Rhode Island law.

inv-02: Limitations and Frequencies — Coverage limitations and frequency constraints

Coverage limitations and frequency constraints

Fluoride Varnish Limits: Fluoride varnish is limited to members age 6 months through 18.99 years, must be rendered by the member's PCP or covering practitioner, and is limited to 4 units per calendar year.4 units/year

Early Intervention services must be rendered by state certified providers for qualified members up to age 3.age <= 3

CRAFFT Screening: CRAFFT screening (substance use screening in adolescents) is limited to 1 unit per calendar year for ages 11–21.1 unit/year ages 11-21

Development/Autism Screening: Pediatric development screening and pediatric autism screening are each limited to up to 5 services through age 3 when rendered by the member's PCP or covering practitioner; for members age 3–21 these screenings are limited to 1 per year.5 services <= age 3; then 1/year age 3-21

Ocular Photoscreening Authorization: Ocular photoscreening is covered without authorization for ages 6 months up to 5 years; members age 5 and older require authorization.authorization required for age >=5

Prenatal pediatric visit limit: Prenatal pediatric visit is limited to no more than 2 visits, up to 30 minutes per visit.max 2 visits, 30 minutes each

Pediatric COVID counseling age limit: Pediatric COVID vaccine counseling is limited to members up to and including age 21.age <= 21

inv-03: Exclusions — Exclusions and noncovered conditions

Exclusions and noncovered conditions

Exclusions: Routine dental care is not covered for Medicaid members (refer RIte Smiles for children born on/after May 1, 2000); vision screening (CPT 99172, 99173) and hearing screening (CPT 92551) are part of the routine pediatric visit and are not separately billable; pediatric COVID counseling is not covered when there is no scheduled office visit that day.

inv-04: COVID vaccine counseling — Covered when billed with required modifiers on same day as visit

Covered when billed with required modifiers on same day as visit

COVID vaccine counseling modifier criteria: Counseling codes 99401–99404 are covered when billed on the same day as a scheduled preventive or sick visit and submitted with both modifier CR and modifier 25; these counseling codes may be billed once per individual member per day and member cost sharing for the counseling service is waived.CR and 25 modifier present

Member cost sharing for counseling is waived; cost sharing may apply to the office visit code.

inv-05: Pediatric Developmental/Autism Screening — Covered when billed with required diagnosis and screening code

Covered when billed with required diagnosis and screening code

Developmental screening: Pediatric developmental screening services must be billed with diagnosis code Z00.121 or Z00.129 and with code 96110 (developmental screening with scoring and documentation).Diagnosis Z00.121 or Z00.129 + 96110

Autism screening: Pediatric autism screening services must be billed with diagnosis code Z00.121 or Z00.129 and with code 96110 plus modifier U1 as specified for autism screening.Diagnosis Z00.121 or Z00.129 + 96110 with modifier U1

Routine dental care is not covered for Medicaid members. For RIte Care eligible children born on or after May 1, 2000, refer to the RIte Smiles program for dental coverage. Vision screening (CPT 99172, 99173) and hearing screening (CPT 92551) are considered part of the routine pediatric visit and are not separately billable. Pediatric COVID vaccine counseling is not covered when there is no scheduled office visit on the same day.

The document history records that the policy removed Table 4 requirements for Fluoride Varnish as of 07/01/2024. This indicates prior detailed billing or coding constraints contained in Table 4 are no longer part of the policy requirements.

All services must be medically necessary to qualify for reimbursement. Neighborhood may apply National Coverage Determinations (NCD), Local Coverage Determinations (LCD), industry-accepted criteria such as InterQual, Rhode Island EOHHS recommendations, and Clinical Medical Policies (CMP) when assessing medical necessity; services that fail to meet these standards may be considered not medically necessary and can be denied.

Coding, Billing, and Frequency Rules

Covered CPT/HCPCS Codes (listed in policy)mixedCovered

92522	Evaluation of speech sound production
92523	Evaluation of speech sound production with evaluation of language comprehension and expression
92557	Comprehensive audiometry threshold evaluation and speech recognition
96112	Developmental test administration; first hour
96113	Developmental test administration; each additional 30 minutes
97161	Physical therapy evaluation: low complexity
97162	Physical therapy evaluation: low complexity (alternate descriptor)
97163	Physical therapy evaluation: high complexity
97164	Re-evaluation of physical therapy established plan of care
97165	Occupational therapy evaluation, low complexity

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Not separately billable when part of 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)

Pediatric COVID counseling codes (require modifiers CR and 25; billed once per member per day)CPTCovered

99401	Pediatric COVID vaccine counseling
99402	Pediatric COVID vaccine counseling
99403	Pediatric COVID vaccine counseling
99404	Pediatric COVID vaccine counseling

Modifiers/Payment RulesModifier

CR	Catastrophe/disaster related modifier required when billed same day as scheduled preventive or sick visit
25	Significant, separately identifiable E/M service on same day modifier required when billed with counseling codes

Preventive medicine CPT codesCPTCovered

99383	Initial comprehensive preventive medicine E/M, age 1-4 years, new patient
99384	Initial comprehensive preventive medicine E/M, age 5-11 years, new patient
99385	Initial comprehensive preventive medicine E/M, adolescent 12-17 years, new patient
99391	Periodic comprehensive preventive medicine reevaluation and management, 18-39 years, established patient
99392	Periodic comprehensive preventive medicine reevaluation and management, infant <1 year, established patient
99393	Periodic comprehensive preventive medicine reevaluation and management, age 1-4 years, established patient
99394	Periodic comprehensive preventive medicine reevaluation and management, age 5-11 years, established patient
99395	Periodic comprehensive preventive medicine reevaluation and management, adolescent 12-17 years, established patient

Additional HCPCS/other codesmixedCovered

D1206	Topical fluoride varnish; therapeutic application for moderate to high caries risk patients
H0046	Mental health services, not otherwise specified
H2000	Comprehensive multidisciplinary evaluation
S0302	Completed EPSDT service (list in addition to code for appropriate evaluation and management service)
S9446	Patient education, 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 to determine appropriateness for program participation, per encounter
T1024	Evaluation and treatment by integrated specialty team contracted to provide coordinated care, per encounter

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Counseling and screening CPT codesCPTCovered

99401	Preventive medicine counseling/risk factor reduction, ~15 minutes
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
96110	Developmental screening with scoring and documentation, per standardized instrument

Diagnosis codes required for pediatric developmental/autism screeningICD-10

Z00.121	Routine child health exam with abnormal findings (used for pediatric developmental/autism screening billing)
Z00.129	Routine child health exam without abnormal findings (used for pediatric developmental/autism screening billing)

Fluoride varnish annual limit

Annual limit4 units per calendar year

Age range6 months to 18.99 years

Provider requirementMust be rendered by member's PCP or covering practitioner

CRAFFT screening frequency

Frequency1 unit per calendar year

Age range

Provider Requirements, Authorization, and Documentation

Prior Authorization

Prior Authorization Required for Ocular Photoscreening

Ocular photoscreening for members age 5 and older requires prior authorization; ocular photoscreening for members younger than 5 does not require authorization.

Affected service: Ocular photoscreening
Age 6 months–<5 years: no authorization required
Age ≥5 years: prior authorization required

Denial Risk

Denial Risk — Pediatric COVID Counseling Provided Alone

Pediatric COVID counseling is not covered when provided as a standalone service on a day with no scheduled office visit for the member. Such standalone counseling encounters may be denied.

Pediatric COVID counseling coverage limited to members age ≤21 years (see Coverage Limitations)

Background and Scope

Pediatric preventive care encompasses routine well-child and sick visits, age-appropriate screenings, immunizations, and early intervention for identified developmental delays. Coverage aligns with American Academy of Pediatrics guidance and Rhode Island law and includes services such as prenatal pediatric visits, fluoride varnish application, ocular photoscreening, pediatric developmental and autism screening, and Early Intervention services for qualified children up to age 3. Providers should bill services consistent with the policy-specific coding and frequency limits.

Key Definitions

Early Intervention services

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

Provider typeState-certified Early Intervention (EI) providers

Eligibility ageBirth through age 3

Pediatric COVID vaccine counseling

Service descriptionCounseling provided the same day as a scheduled preventive or sick visit

Billing rulesBilled once per member per day using CPT codes 99401-99404 with modifiers CR and 25

Cost sharing

Policy Revision History

2024-07-01annual_reviewLatest

Annual review; removed Table 4 requirements for Fluoride Varnish.

2023-05-09coding_update

Added Table 3 and Table 4 to the coding grid with specific requirements for Pediatric Developmental/Autism Screenings and Fluoride Varnish.

2023-01-01authorization_change

OpenPayer

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