CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Children's Care Services (Pediatric Preventive & Screening Services)

Defines coverage, limits, and billing codes for pediatric preventive care, developmental/autism, vision and hearing screenings, fluoride varnish, early intervention, school-based health center services, and related visits for members up to age 21 (child defined as up to 18.99 in claims). Affects PCPs, state-certified early intervention providers, and school-based health centers serving Neighborhood Health Plan of Rhode Island members.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyChildren's Care Services (Pediatric Preventive & Screening Services)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization for pediatric development & autism screening and ocular photoscreening for members age 5 and older; ensure Early Intervention claims show state-certified EI provider credentials.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

4fluoride varnish annual limit

5dev & autism screening limit (<=3 yrs)

26mo–<5yrocular photoscreening without auth

≤3yrEarly Intervention eligibility

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Coverage Criteria and Service Scope

Service-specific coverage criteria

Covered when ALL of the following are met

General eligibility: Member is enrolled in applicable children's benefit packages (e.g., RIte Care, Children with Special Health Care Needs, Substitute Care) and services are provided within the age and setting limits described in this policy (services generally apply to children up to age 21; note claim system defines child as up to 18.99).age criteria per service

See service-specific nodes for exact age ranges and authorization requirements.

Fluoride varnish (HCPCS D1206) is provided by the member's PCP or covering practitioner to members age 6 months through 48 months; billed using HCPCS D1206.6 months to 48 months; limit: up to 4 units per calendar year

Refer to coding group for HCPCS D1206.

Pediatric development & autism screening (PCP office): Pediatric development and autism screening (CPT 96110) in the PCP's office is limited to up to 5 services through age 3 without prior authorization; for ages 3 through 19 one screening per year is allowed without authorization; members age 5 and older require prior authorization for this screening service.<=5 services up to age 3 without authorization; 1 per year for ages 3–19 without authorization; authorization required for members >=5 years per prior authorization rules

CPT 96110; see authorization module for details.

Ocular photoscreening (CPT 99174) is limited without authorization to members age 26 months through under 5 years; members age 5 years and older require prior authorization.26 months to <5 years without authorization

CPT 99174; authorization required for >=5 years.

Early Intervention services: Early Intervention Program (EIP) services (CPT/HCPCS codes as listed) are covered for qualified children from birth up to age 3 when rendered and billed by state-certified Early Intervention providers only.birth to age 3; payable only to state-certified EI providers

EIP CPT examples: 92506, 92522, 92523, 92557, 96111, 97001, 97003, 99205; EIP HCPCS examples: H0046, S9446, T1027, T2004, T5999, V2799.

School-based health centers: Services provided in School Based Health Centers are covered for members older than 11 and less than 21, and may include well and sick visits, immunizations, chronic care visits, and physicals as appropriate to the setting.age >11 and <21

Place of service includes POS 03 (school); applicable CPT codes include the pediatric preventive and office visit ranges listed in coding.

These pediatric preventive and screening services do not apply to members of Rhody Health Plan (RHP), members aged 21 and older, or members enrolled only in Extended Family Planning (EFP), as EFP members do not have a comprehensive benefit package. Routine dental care is 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 the RI EPSDT schedule, vision screening (CPT 99172, 99173) and hearing screening (CPT 92551) are considered components of the annual pediatric preventive visit and are bundled into that visit. These screenings are not separately billable when performed as part of the routine annual pediatric visit.

Billing Codes and Limits

Covered HCPCSHCPCSCovered

D1206

Fluoride Varnish (HCPCS)

Covered CPT Codes (selected ranges and examples)CPTCovered

96110	Pediatric Development and Autism Screening (CPT)
99174	Ocular Photoscreening (CPT)
99381	Pediatric Preventive Care CPT range (part)
99382	Pediatric Preventive Care CPT range (part)
99383	Pediatric Preventive Care CPT range (part)
99384	Pediatric Preventive Care CPT range (part)
99385	Pediatric Preventive Care CPT range (part)
99391	Pediatric Preventive Care CPT range (part)
99392	Pediatric Preventive Care CPT range (part)
99393	Pediatric Preventive Care CPT range (part)

1–10 of 17

1/2

Early Intervention CPT CodesCPTCovered

92506	Early Intervention related CPT (speech eval)
92522	Early Intervention related CPT
92523	Early Intervention related CPT
92557	Early Intervention related CPT
96111	Developmental testing
97001	Physical therapy eval (EIP)
97003	Physical therapy re-eval (EIP)
99205	EIP related CPT (high-level office visit)

Early Intervention HCPCS/otherHCPCSCovered

H0046	Community psychiatric supportive treatment (HCPCS) - listed for EIP
S9446	Home health aide - listed for EIP
T1027	Non-emergency transportation (HCPCS) - listed for EIP
T2004	Other therapy services (HCPCS) - listed for EIP
T5999	Miscellaneous therapeutic services - listed for EIP
V2799	State-specific code listed

ICD-9 Diagnosis Codes referencedICD-10

V20.2	Pediatric development and autism screening (ICD-9 diagnosis listed)
V07.31	Fluoride varnish ICD-9 diagnosis listed
V65.11	Prenatal Pediatrician Office Visit ICD-9 diagnosis
V2135	Pediatric preventive care ICD-9 diagnosis (partial)

inv-09: Fluoride varnish units per calendar year

Annual limit4 units per calendar year

Eligible age rangeMember age 6 months to 48 months

Billing codeHCPCS D1206 (Fluoride Varnish)

ProviderService must be rendered by member's PCP or covering practitioner

Authorizations, Claims, and Documentation Requirements

Prior Authorization

Prior Authorization Required

Certain pediatric screening and photoscreening services require prior authorization when performed for older children. Providers must request authorization before rendering these services for members age 5 years and older to avoid claim denials or retrospective review.

Pediatric development & autism screening: Authorization required for age ≥ 5 years; ages 0–3 limited to 5 services without authorization; ages 3–19 limited to one service per year without authorization.
Ocular photoscreening (CPT 99174): Authorization required for members ≥ 5 years; ages 26 months to <5 years permitted without authorization.

Note

Provider Action — Key Steps

Providers should follow these high-level actions to reduce denials and ensure timely processing.

Confirm member age and eligibility before scheduling screenings or photoscreening.
Obtain prior authorization when required (see authorization triggers).

Policy Background and Rationale

Early Periodic Screening, Diagnostic, and Treatment (EPSDT)–related services covered here include routine well-child visits, developmental and autism screening, fluoride varnish applications, ocular photoscreening, and Early Intervention services for eligible children. Early Intervention services must be rendered by state-certified EI providers and are limited to qualified children up to age 3. Note that certain services are incorporated into the routine EPSDT visit (for example, vision and hearing screening) and therefore are not separately billable when provided as part of that visit.

Key Definitions

inv-15: Definition of 'child' for claims (child = <= 18.99)

DefinitionChild = member up to age 18.99 in Neighborhood's claims system

PurposeAligns with RI Department of Health State Supplied Vaccine Program

Applies toAll Children's Care Services benefit rules and claims processing

inv-16: Early Intervention (EI) — services rendered by state-certified EI providers up to age 3

Age eligibilityCovered for qualified members from birth up to age 3 years

Provider requirementServices payable only when rendered by state-certified Early Intervention (EI) providers