CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

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

Governs coverage, limitations, coding, and billing for pediatric preventive, screening, and related children's services for Neighborhood Health Plan of Rhode Island members (Medicaid excluding EFP/RHP/RHE and Commercial).

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

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

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionVerify member eligibility and obtain authorization when services exceed listed limits (for example developmental/autism screening beyond age‑specific limits or ocular photoscreening for age 5 and older).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

4annual fluoride varnish units allowed per member

5developmental screening visits allowed up to age 3

15+listed procedure and service codes

Specifiedage-based preventive visit CPT codes

Coverage Criteria for Pediatric Preventive and Related Services

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Covered Services with Criteria

Covered when services are medically necessary and meet program-specific limits and provider qualifications.

General coverage requirements: Services must be medically necessary and provided in accordance with American Academy of Pediatrics guidance and Rhode Island law; provider must verify member eligibility and any required prior authorization before rendering services.

Neighborhood may use NCD/LCD, Interqual, EOHHS recommendations, or Clinical Medical Policies to determine medical necessity.

Included services: Prenatal pediatric office visit; well-child, routine, and sick pediatric visits; pediatric screenings (developmental, autism, CRAFFT); fluoride varnish; early intervention for eligible children birth to age 3; ocular photoscreening.

See service-specific limits for age ranges and limits.

Service-specific limits: Fluoride varnish: ages 6 months to 18.99 years, annual limit 4 units per calendar year; CRAFFT screening: ages 11–21, 1 unit per calendar year; Pediatric development screening: up to 5 services through age 3 without authorization; Pediatric autism screening: up to 5 services through age 3 without authorization; Development or autism screening for ages 3–21: limited to 1 per year without authorization; Ocular photoscreening: covered without authorization for ages 6 months up to 5 years, age 5 and older requires authorization; Prenatal pediatric visit: limited to no more than 2 visits, up to 30 minutes each; Pediatric COVID counseling: limited to children up to and including age 21 and must be billed consistent with same-day scheduled visit requirements.

Early intervention services must be rendered by state-certified providers for qualified members up to age 3.

Preventive visit and counseling coverage

Covered when billed with the appropriate age-based preventive medicine CPT code and supporting documentation of the encounter.

Preventive visit coverage: Initial (CPT 99381–99385) and periodic (CPT 99391–99395) comprehensive preventive medicine E/M codes are covered when submitted for the member's applicable age group and include age-appropriate history, examination, counseling/anticipatory guidance or risk-reduction interventions, and any ordered laboratory/diagnostic procedures.

See coding tables for exact age mappings to CPT codes.

Ancillary/supportive services

Additional services that support preventive care are covered when appropriately billed and documented.

Supportive service codes: The following HCPCS/T codes are listed as covered or referenced in association with preventive visits when appropriately billed: D1206 (topical fluoride varnish), H0046, H2000, S0302, S9446, T1013–T1027, T2004, T5999, V2799, V5008, V5010.

Includes EPSDT-related and mental/rehabilitative supportive services; provider must follow program rules for state-certified services (eg, Early Intervention).

Preventive counseling coverage

Preventive counseling may be billed as a separate procedure when documented to support the time and content of counseling provided.

Separate counseling procedures: CPT codes 99401–99404 are covered for preventive medicine counseling and/or risk-reduction interventions as separate procedures; documentation must support the counseling time and content.

Approximate durations: 99401 ≈15 minutes; 99402 ≈30 minutes; 99403 ≈45 minutes; 99404 ≈60 minutes.

Routine dental care is not covered for Medicaid members. For RIte Care–eligible children born on or after May 1, 2000, providers should 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. Additionally, pediatric COVID counseling will be denied if there is no scheduled office visit on the same day.

This payment policy is provided for informational purposes only and is not a guarantee of reimbursement. Claim payment and processing depend on member benefit coverage, eligibility, claims payment edit rules, coding and documentation guidelines, authorization policies, provider contract agreements, and applicable state and federal regulations. Implementation details may vary across Neighborhood’s electronic claims processing systems due to programming or other constraints.

All services must be medically necessary to qualify for reimbursement. Neighborhood may determine medical necessity using National Coverage Determinations (NCD), Local Coverage Determinations (LCD), industry-accepted criteria such as Interqual, Rhode Island EOHHS recommendations, and Neighborhood Clinical Medical Policies (CMP). Providers are responsible for verifying member eligibility, coverage, and any authorization requirements prior to delivering services.

The source material does not contain explicit statements listing services as ‘not medically necessary.’ References in this policy explain the medical necessity criteria and related authorization and coverage processes but do not enumerate specific services labeled as not medically necessary within the cited text.

Coding and Service Limits

Covered CPT/HCPCS Codes (examples listed in policy)mixedCovered

99401	Pediatric COVID vaccine counseling (billable as listed)
99402	Pediatric COVID vaccine counseling (billable as listed)
99403	Pediatric COVID vaccine counseling (billable as listed)
99404	Pediatric COVID vaccine counseling (billable as listed)
CR	Modifier required for pediatric COVID counseling
25	Modifier required when counseling provided the same day as another service
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
96110	Developmental screening with scoring and documentation

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Preventive medicine CPT codesCPTCovered

99381	Initial comprehensive preventive medicine evaluation and management, new patient; infant (age younger than 1 year)
99382	Initial comprehensive preventive medicine evaluation and management, new patient; early childhood (age 1 through 4 years)
99383	Initial comprehensive preventive medicine evaluation and management, new patient; late childhood (age 5 through 11 years)
99384	Initial comprehensive preventive medicine evaluation and management, new patient; adolescent (age 12 through 17 years)
99385	Initial comprehensive preventive medicine evaluation and management, new patient; 18-39 years
99391	Periodic comprehensive preventive medicine reevaluation and management, established patient; infant (age younger than 1 year)
99392	Periodic comprehensive preventive medicine reevaluation and management, established patient; early childhood (age 1 through 4 years)
99393	Periodic comprehensive preventive medicine reevaluation and management, established patient; late childhood (age 5 through 11 years)
99394	Periodic comprehensive preventive medicine reevaluation and management, established patient; adolescent (age 12 through 17 years)
99395	Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, established patient; 18-39 years

Additional HCPCS/T codes referencedHCPCSCovered

D1206	Topical application of fluoride varnish
H0046	Mental health services, not otherwise specified
H2000	Comprehensive multidisciplinary evaluation
S0302	Completed early periodic screening diagnosis and treatment (EPSDT) 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 to determine appropriateness for program participation, per encounter
T1024	Evaluation and treatment by integrated specialty team, per encounter

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Preventive counseling separate procedure codesCPTCovered

99401	Preventive medicine counseling and/or risk factor reduction interventions; approximately 15 minutes
99402	Preventive medicine counseling and/or risk factor reduction interventions; approximately 30 minutes
99403	Preventive medicine counseling and/or risk factor reduction interventions; approximately 45 minutes
99404	Preventive medicine counseling and/or risk factor reduction interventions; approximately 60 minutes

Fluoride varnish annual limit

Limit4 units per calendar year

Age rangeMember age 6 months to 18.99 years

ProviderRendered by the member's PCP or covering practitioner

CRAFFT screening frequency

Limit1 unit per calendar year

Age rangeAges 11 through 21 years

ServiceCRAFFT screening (substance use in adolescence)

Pediatric development/autism screening without authorization (age <3)

LimitUp to 5 services without authorization

Age rangeMembers younger than 3 years (birth up to age 3)

ProviderRendered by the member's PCP or covering practitioner

Pediatric development/autism screening without authorization (age 3-21)

Limit1 per year without authorization

Age rangeMembers age 3 through 21 years

ProviderRendered by the member's PCP or covering practitioner

Counseling duration

99401Preventive medicine counseling — approximately 15 minutes

99402Preventive medicine counseling — approximately 30 minutes

99403Preventive medicine counseling — approximately 45 minutes

99404Preventive medicine counseling — approximately 60 minutes

Provider Actions, Authorization, and Documentation Requirements

Prior Authorization

Authorization Required for Services Beyond Specified Limits

Authorization is required for services that exceed the limits listed in this policy. Examples include pediatric development/autism screening beyond the specified number of visits, and ocular photoscreening for members age 5 years and older. Providers must verify and obtain any required prior authorization before rendering services that exceed these limits.

Pediatric Development Screening: limited to 5 services up to age 3 without authorization; additional services require authorization.
Pediatric Autism Screening: limited to 5 services up to age 3 without authorization; additional services require authorization.
Pediatric Development or Autism Screening for ages 3–21: limited to 1 per year without authorization; additional services require authorization.
Ocular Photoscreening: covered without authorization for ages 6 months–5 years; ages 5 and older require authorization.

Prior Authorization

Prior Authorization — See Payer Authorization Policies

Prior authorization requirements referenced in this policy are governed by Neighborhood's payer authorization policies. Providers are responsible for checking plan-specific authorization rules and obtaining prior authorization where required before providing services.

Refer to Neighborhood's Prior Authorization Reference page for procedure- and service-specific authorization requirements.
Contact Provider Services at 1-800-963-1001 with questions about authorization requirements.

Denial Risk

Services Not Medically Necessary May Be Denied

Services that do not meet Neighborhood's medical necessity criteria may be denied. Neighborhood may apply NCDs, LCDs, Interqual, EOHHS guidance, and Clinical Medical Policies when determining medical necessity. Providers must ensure services billed are medically necessary and supported by documentation.

Medical necessity sources: NCD, LCD, Interqual, EOHHS recommendations, Clinical Medical Policies.
Failure to meet medical necessity criteria may result in claim denial or recoupment.

Denial Risk

Pediatric COVID Counseling Denial Condition

Pediatric COVID counseling is only covered when rendered in conjunction with a scheduled office visit on the same day. Counseling for pediatric COVID without a scheduled office visit that day is not covered and will be denied.

Pediatric COVID counseling is limited to children up to and including age 21.
If there is no scheduled office visit for the member on the day counseling is provided, the service will be denied.

Documentation Required

Medical Record Retention and Audit

Providers must retain medical records that substantiate services billed and the medical necessity of those services. Neighborhood may request medical records and will follow claim review and audit processes; failure to produce records may result in claim denial or recoupment.

Retain complete medical records in accordance with applicable laws and contractual requirements.
Be prepared to submit records upon Neighborhood's request to support billed services and medical necessity.

Documentation Required

Documentation and Coding Requirements

Documentation and coding must support billed services and the medical necessity for those services. Claims are subject to coding and documentation review and must follow CPT, ICD-10-CM, and HCPCS standards. References to CPT or other sources are for definitional purposes only.

Use AMA CPT®, ICD-10-CM, and HCPCS Level II code sets as applicable when billing.
Ensure medical record documentation clearly supports the codes billed, clinical indications, and medical necessity.
Incomplete or inconsistent documentation/coding may result in claim denial or adjustment.

Billing Rule

Claim Denial Risks and Provider Responsibilities

Claims may be denied for eligibility, coding, documentation, or authorization failures. Providers should verify member eligibility, follow authorization requirements, and ensure accurate coding and supportive documentation prior to claim submission.

Verify member eligibility and coverage prior to providing services.
Obtain prior authorization when required and maintain documentation.
Submit complete and correctly coded claims within timely filing limits.

OpenPayer

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

Coverage Criteria for Pediatric Preventive and Related Services

Coding and Service Limits

Provider Actions, Authorization, and Documentation Requirements

Definitions and Code Notes

Background and Policy Context

Policy Revision History