CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Immunizations and Vaccinations Coverage

Defines Neighborhood Health Plan of Rhode Island coverage, billing, and limits for immunizations and vaccine administrations for Medicaid, INTEGRITY, and Commercial members; applies to providers submitting claims to NHPRI.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyImmunizations and Vaccinations Coverage

Policy CodePolicy N/A

Change TypeRemoved PCP requirementadded RSV codesremoved COVID-19 coding

Effective DateN/A

Next Review DateN/A

Key ActionVerify member eligibility and authorization requirements and submit paired vaccine and administration codes to avoid claim denials.

SourceLink

POLICY UPDATE CHANGES

Removed PCP Requirement for vaccines.

Added RSV vaccine and administration codes and removed obsolete COVID-19 coding and requirements.

15max administrations/day

2shingles limit (lifetime)

3HPV limit (lifetime)

Medicaid, INTEGRITY, Commerciallines of business

Coverage Criteria

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General coverage

Covered when ALL of the following are met

General coverage: Immunizations and vaccinations for treatment of disease or prevention of infectious disease when medically necessary and aligned with RI Department of Health State Supplied Vaccine Schedule or additional vaccines approved by Neighborhood's Clinical Management Committee

Includes administrations across provider settings; administration reimbursed even when vaccine is state supplied

State-supplied and additional vaccines

Coverage specifics

State-supplied vaccine billing: State supplied vaccines are provided by the Department of Health (DOH) at no cost to providers; vaccine product charges are not reimbursed though administration is reimbursed

Providers should not expect vaccine reimbursement for state-supplied products; CDC-approved influenza vaccine administration is covered regardless of vaccine supply source

Coverage outside state schedule: Neighborhood may reimburse specific vaccine CPT codes for ages outside the RI DOH schedule; inclusion of a code in the list does not guarantee reimbursement

See coding section for the list of vaccine CPT codes that may be covered

Limits

Coverage limits

Shingles limit: Shingles vaccines limited to two (2) per lifetime2 per lifetime

Applies across lines unless otherwise specified

HPV limit: HPV vaccine limited to three (3) per lifetime3 per lifetime

Daily administration cap: Up to fifteen (15) administrations reimbursable per day<=15 per day

For Medicaid and INTEGRITY members, vaccines and immunizations provided for the purpose of travel are not covered. Providers should verify member eligibility and benefit design prior to administering or billing travel-related vaccines for these lines of business.

The presence of a CPT code in Neighborhood’s listings denotes that the vaccine or administration code is tracked by the policy but does not guarantee reimbursement. Actual payment depends on contractual agreements and medical necessity determinations; providers must confirm coverage and any authorization requirements before billing.

Billing & Coding

Vaccines potentially covered outside RI DOH scheduleCPTCovered

90611	Smallpox and monkeypox vaccine, attenuated vaccinia virus, live, non- replicating, preservative free, 0.5 mL dosage, suspension, for subcutaneous use.
90620	Meningococcal recombinant protein and outer membrane vesicle vaccine, serogroup B (MenB-4C), 2 dose schedule, for intramuscular use.
90622	Vaccinia (smallpox) virus vaccine, live, lyophilized, 0.3 mL dosage, for percutaneous use.
90636	Hepatitis A and hepatitis B vaccine (HepA-HepB), adult dosage, for intramuscular use.
90677	Pneumococcal conjugate vaccine, 20 valent (PCV20), for intramuscular use.
90681	Rotavirus vaccine, human, attenuated (RV1), 2 dose schedule, live, for oral use (Medicaid and Commercial Only).
90710	Measles, mumps, rubella, and varicella vaccine (MMRV), live, for subcutaneous use.
90713	Poliovirus vaccine, inactivated (IPV), for subcutaneous or intramuscular use.
90733	Meningococcal polysaccharide vaccine, serogroups A, C, Y, W-135, quadrivalent (MPSV4), for subcutaneous use.
90736	Zoster (shingles) vaccine (HZV), live, for subcutaneous injection.

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Commercial covered travel vaccinesCPTCovered

90585	Bacillus Calmette-Guerin vaccine (BCG) for tuberculosis, live, for percutaneous use.
90690	Typhoid vaccine, live, oral.
90691	Typhoid vaccine, Vi capsular polysaccharide (ViCPs), for intramuscular use.
90717	Yellow fever vaccine, live, for subcutaneous use.
90738	Japanese encephalitis virus vaccine, inactivated, for intramuscular use.

Administration codesCPT | HCPCSCovered

90460	Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; first or only component of each vaccine or toxoid administered.
90461	Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; each additional vaccine or toxoid component administered (List separately in addition to code for primary procedure).
90471	Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); 1 vaccine (single or combination vaccine/toxoid).
90472	Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); each additional vaccine (single or combination vaccine/toxoid).
90473	Immunization administration by intranasal or oral route; 1 vaccine (single or combination vaccine/toxoid).
90474	Immunization administration by intranasal or oral route; each additional vaccine (single or combination vaccine/toxoid) (List separately in addition to code for primary procedure).
90480	Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, single dose.
96380	Administration of respiratory syncytial virus, monoclonal antibody, seasonal dose by intramuscular injection, with counseling by physician or other qualified health care professional.
96381	Administration of respiratory syncytial virus, monoclonal antibody, seasonal dose by intramuscular injection.
G0008	Administration of influenza virus vaccine (INTEGRITY only).

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inv-09: Daily administration cap

Daily administration capUp to fifteen (15) administrations reimbursable per day

ScopeApplies across provider settings and lines unless otherwise specified

Related limitsAlso note shingles limited to 2 per lifetime and HPV limited to 3 per lifetime

Provider Actions & Requirements

Prior Authorization

Medical necessity and prior authorization

All services must be medically necessary to qualify for reimbursement. Neighborhood may use National Coverage Determinations (NCD), Local Coverage Determinations (LCD), industry-accepted criteria such as InterQual, Rhode Island EOHHS recommendations, and Neighborhood Clinical Medical Policies to determine medical necessity. It is the provider's responsibility to verify member eligibility, coverage, and any prior authorization criteria before rendering services. For plan-specific prior authorization details, refer to Neighborhood's Prior Authorization Reference page or Clinical Medical Policies. Contact Provider Services at 1-800-963-1001 with questions.

Billing Rule

Claims pairing requirement

Vaccine administration codes must be billed together with the corresponding vaccine product code. Administration codes submitted without the associated vaccine code will be denied. Submit complete and timely claims that comply with CPT, ICD-10-CM, and HCPCS coding standards and contractual timely filing requirements.

Administration codes billed without corresponding vaccine (product) code — denial risk
Follow AMA CPT, ICD-10-CM, and HCPCS Level II coding guidance
Adhere to payer contractual timely filing guidelines

Documentation Required

Medical record and eligibility verification

Providers must maintain medical records that support billed services and the medical necessity of those services. Neighborhood may request medical records to validate claims. Documentation must meet CMS standards for proper medical record documentation and be available upon request to support coverage and payment decisions.

Note

Provider action: verify eligibility and authorizations

Providers must verify member eligibility, benefits, and whether prior authorization is required before providing services. Failure to verify eligibility or obtain required authorizations may result in claim denials or member liability.

OpenPayer

Immunizations and Vaccinations Coverage

Coverage Criteria

Billing & Coding

Provider Actions & Requirements

Background

Definitions