CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Immunization and Vaccine Payment Policy

Defines reimbursement and billing rules for immunizations and vaccine administrations across Medicaid, INTEGRITY, and Commercial lines; includes covered vaccine codes, administration codes, limits, exclusions, documentation and claim submission requirements. Applies to providers billing Neighborhood Health Plan of Rhode Island.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyImmunization and Vaccine Payment Policy

Policy CodePolicy N/A

Change TypeRevisions (multiple dates)

Effective Date

Next Review Date

Key ActionProviders must bill vaccine HCPCS/CPT code along with appropriate administration code; administration codes submitted without corresponding vaccine code will be denied.

SourceLink

POLICY UPDATE CHANGES

03/19/2025 Annual policy review. Removed PCP Requirement for vaccines.

03/11/2024 Annual review. Added RSV vaccine and administration codes, removed obsolete COVID-19 coding and requirements, added grid for PCP required vaccines.

03/29/2023 Removed PCP limitation from Medicaid and Commercial.

01/01/2023 Policy Review Date. Updated COVID vaccine/administration table to include new codes. Removed language under INTEGRITY COVID section - no longer need to bill original Medicare, NHP reimburses.

11/12/2021 Combined COVID Vaccine Payment Policy with Immunization and Vaccine Payment Policy. Added pediatric COVID vaccine and admin codes, Moderna and Janssen booster codes. Updated COVID vaccine/administration requirements for Integrity members effective 1/1/22.

15Max administrations reimbursable per day

Shingles lifetime limit

MultipleLines of business covered

Policy Overview

Background: Neighborhood covers immunizations and vaccines for treatment or prevention that align with the Rhode Island Department of Health State Supplied Vaccine Schedule. In addition to the RI DOH schedule, Neighborhood's Clinical Management Committee may approve coverage of additional immunizations and vaccines consistent with its contractual obligations with the Department of Human Services.

Scope summary: This policy applies to Medicaid, INTEGRITY, and Commercial lines of business and defines reimbursement and billing rules for immunizations and vaccine administrations. Providers must verify eligibility, coverage and authorization prior to rendering services and bill vaccine HCPCS/CPT codes along with the appropriate administration codes; administration codes submitted without the corresponding vaccine code will result in denial. State-supplied vaccines are provided at no cost to providers (vaccine product not reimbursed) but administration is covered. Documentation supporting billed services and medical necessity may be requested per CMS standards. Recent document history includes removal of the PCP requirement for vaccines (03/19/2025) and other code and requirement updates noted in the policy history.

Top-level Policy

policy_titleImmunization and Vaccine Payment Policy

payerNeighborhood Health Plan of Rhode Island

policy_numberN/A

statusCURRENT

last_review2025-03-19

effective_date

scope_summaryDefines reimbursement and billing rules for immunizations and vaccine administrations across Medicaid, INTEGRITY, and Commercial lines; includes covered vaccine codes, administration codes, limits, exclusions, documentation and claim submission requirements. Applies to providers billing Neighborhood Health Plan of Rhode Island.

Key ActionBill vaccine HCPCS/CPT code together with the appropriate administration code; verify member eligibility, coverage and authorization prior to service.

Coverage Criteria & Limits

General Coverage / Medical Necessity

Immunizations and vaccinations are covered when medically necessary and align with referenced guidance. Neighborhood may use the following to determine medical necessity:

General medical necessity criteria

Medical necessity: Service must be medically necessary.
References for determination: Coverage determination may reference National Coverage Determination (NCD), Local Coverage Determination (LCD), industry accepted criteria such as InterQual, Rhode Island EOHHS recommendations, and Neighborhood Clinical Medical Policies.
Provider responsibility: Providers must verify eligibility, coverage and authorization prior to rendering services.
Refer to plan-specific Prior Authorization Reference page as needed.

Coding & Claim Submission Rules

Claim Submission / Billing Requirement

Claims will be paid only when the following billing rules are followed:

Timely filing: Billable services are subject to contractual timely filing guidelines.

Coding standards: Coding must meet CPT, ICD-10-CM, and HCPCS Level II standards.

Vaccine + administration required: Vaccine codes must be billed to NHPRI along with the appropriate administration codes; administration codes submitted without corresponding vaccine code will result in denial.

Documentation: Neighborhood may request medical records; documentation must support billed service(s) and medical necessity. Follows CMS documentation standards.

Provider Action Items

Billing Rule

Submit vaccine product with administration code

Providers must bill the vaccine product HCPCS/CPT code on the claim along with the appropriate administration code to be eligible for reimbursement. Administration codes submitted without the corresponding vaccine code will be denied. Denial risk: submitting an administration code without the vaccine product code will result in claim denial.

Bill vaccine HCPCS/CPT with matching administration code
Administration-only submissions without vaccine code -> denial

Documentation Required

Maintain medical record documentation

Maintain complete medical record documentation that supports billed services and medical necessity. Neighborhood may request medical records for any billed service. Documentation must follow CMS standards.

Definitions

EFP MembersMembers with a limited benefit package; covered only for state-supplied vaccines and corresponding administrations under their benefit; all other vaccines/administration charges are non-covered.

Limits & Thresholds

Coverage Thresholds

Shingles vaccine lifetime limit<= 2 per lifetime

HPV vaccine lifetime limit<= 3 per lifetime

Daily administration limit<= 15 administrations per day

Policy Revision History

03/19/2025revisedLatest

Annual policy review. Removed PCP Requirement for vaccines.

03/11/2024revised

Annual review. Added RSV vaccine and administration codes, removed obsolete COVID-19 coding and requirements, added grid for PCP required vaccines.

03/29/2023revised

Removed PCP limitation from Medicaid and Commercial.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyImmunization and Vaccine Payment Policy

Policy CodePolicy N/A

Change TypeRevisions (multiple dates)

Effective Date

Next Review Date

Key ActionProviders must bill vaccine HCPCS/CPT code along with appropriate administration code; administration codes submitted without corresponding vaccine code will be denied.

SourceLink

On This Page

title": "General Coverage / Medical Necessity

Coverage Includes - State Supplied Vaccines and Administration

Covered when ALL of the following are met:

State supplied vaccines and administration: State-supplied vaccines provided by the RI Department of Health are provided at no cost to providers; vaccine product charge is not reimbursed but administration is covered.

Flu vaccine administration: Administration charges for all CDC-approved influenza (flu) vaccines are covered regardless of whether vaccine is state-supplied or not (vaccine charge not reimbursed).

Allowed provider settings: Immunizations and vaccines and/or their administrations are covered when administered by any provider (physician office, hospital outpatient department, pharmacy, community health center).

Coverage Includes - Additional Reimbursable Vaccine Codes (outside RI DOH schedule)

Neighborhood may reimburse (inclusion does not guarantee reimbursement):

Additional reimbursable vaccine codes (may be reimbursed): 90611 - Smallpox and monkeypox vaccine, attenuated vaccinia virus, live, non-replicating, preservative free, 0.5 mL dosage, suspension, for subcutaneous use.