ModifiedNeighborhood Health Plan of Rhode IslandPolicy N/A

Immunizations and Vaccines Coverage

This policy governs coverage, reimbursement, and administrative requirements for immunizations and vaccinations for Neighborhood Health Plan of Rhode Island members across Medicaid, INTEGRITY, and Commercial lines, including state-supplied and additional vaccines approved by the plan.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyImmunizations and Vaccines Coverage

Policy CodePolicy N/A

Change TypeAdded COVID codesremoved INTEGRITY billing language

Effective DateN/A

Next Review DateN/A

Key ActionVerify eligibility, coverage, and prior authorization criteria before providing immunizations and bill vaccine CPT codes for data collection while billing administration codes for reimbursement.

SourceLink

POLICY UPDATE CHANGES

Updated COVID vaccine/administration table to include new codes.

Removed language under INTEGRITY COVID section about billing original Medicare and reimbursement by NHP.

Medicaid, INTEGRITY, CommercialApplies to

Up to 15/dayAdmin limit

2 lifetimeShingles limit

3 lifetimeHPV limit

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Coverage and Medical Necessity

General vaccine coverage

Covered when ALL of the following are met

General coverage: Immunizations and vaccinations for treatment of disease or prevention of infectious disease are covered and align with the Rhode Island Department of Health State Supplied Vaccine Schedule; Neighborhood's Clinical Management Committee may approve additional vaccines that align with contractual benefits.

Administration coverage: Administration charges for CDC‑approved influenza vaccines are covered regardless of whether the vaccine product is state‑supplied; state‑supplied vaccine product charges are not reimbursed but administration is reimbursed.

Site of service: Immunizations and vaccine administrations are generally covered when administered by the member's PCP or covering practitioner; exceptions include influenza, rabies, diphtheria, tetanus, pertussis, and COVID vaccines. School‑based health centers, hospital outpatient departments, and community health centers are treated as PCP sites for immunization purposes.

COVID-19 vaccine coverage

COVID-19 vaccines and administrations

Eligible COVID vaccines: This policy applies to FDA‑approved and CDC‑recommended COVID‑19 vaccines, including vaccines authorized via Emergency Use Authorization and vaccines administered during the Rhode Island COVID‑19 State of Emergency.

Billing requirement: Vaccine product codes will not be reimbursed because vaccines are provided at no cost to providers through federal/state programs; providers must continue to bill vaccine CPT codes for data collection and will be reimbursed separately for the administration codes identified in this policy.

Although several travel-related vaccine CPT codes are listed in the coding tables for reference (for example: 90585, 90690, 90691, 90717, 90738), this policy explicitly excludes reimbursement for immunizations and vaccines administered for travel. In other words, travel vaccines are not covered and claims for vaccines given solely for travel purposes are not payable under this policy.

To be reimbursable, vaccine product codes must be billed to Neighborhood Health Plan of Rhode Island together with the appropriate administration code(s). Per the policy, administration codes submitted without the corresponding vaccine code will result in denial. Submit complete claims that include both the vaccine CPT/HCPCS and the matching administration code to avoid claim denials.

CPT / HCPCS Codes and Administration Rules

Covered vaccine CPT codes (selected)CPTCovered

90620	MENINGOCOCCAL (Serogroup B) 2 DOSE, IM
90621	MENINGOCOCCAL (Serogroup B) 3 DOSE, IM
90636	HEP A/HEP B VACCINE ADULT IM
90681	ROTAVIRUS , LIVE, 2 DOSE ORAL
90710	MMRV, LIVE, SUBCU
90713	POLIOVIRUS, INACTIVE, SUBCU OR IM
90733	MENINGOCOCCAL POLYSACCHARIDE, SEROGROUPS A,C,Y,W-135, QUAD, SUBCU
90736	ZOSTER (SHINGLES) LIVE, SUBCU
90740	HEPB VACC, ILL PAT 3 DOSE IM
90750	ZOSTER (shingles) VACC, IM

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Additional covered vaccine CPT/HCPCS codesmixedCovered

90656	FLU VACCINE, TRI, PRSV FREE, 4 YEARS & >, IM
90662	FLU VACC,PRSV FREE INC ANTIG, IM
90689	FLU VACCINE, QUAD IIV4, IM
90670	PNEUMOCOCCAL VACC, PCV13, IM
90732	PNEUMOCOCCAL POLYSACCHARIDE, 23 VALENT, ILL PAT, > 2 YEARS, SUBCU, IM
Q2035	FLU VACCINE, SPLIT, 3 & >, IM (AFLURIA)

COVID-19 vaccine and administration codesmixedCovered

91300	Pfizer-BioNTech COVID-19 Vaccine (mRNA-LNP, 30 mcg/0.3mL)
0001A	Pfizer COVID-19 First Dose administration code
0002A	Pfizer COVID-19 Second Dose administration code
0003A	Pfizer COVID-19 Third Dose administration code
0004A	Pfizer COVID-19 Booster administration code
91301	Moderna COVID-19 Vaccine (mRNA-LNP, 100 mcg/0.5mL)
0011A	Moderna COVID-19 First Dose administration code
0012A	Moderna COVID-19 Second Dose administration code
0013A	Moderna COVID-19 Third Dose administration code
91303	Johnson & Johnson COVID-19 Vaccine (Ad26 vector)

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Travel immunization codes (listed)CPT

90585	Bacillus Calmette-Guerin vaccine (BCG) for tuberculosis, live, for percutaneous use (Listed as travel immunization)
90690	Typhoid vaccine, live, oral (travel immunization)
90691	90691 (listed as travel immunization)
90717	Yellow fever vaccine, live, for subcutaneous use (travel immunization)
90738	90738 (listed as travel immunization)

COVID and immunization CPT/HCPCS codesmixedCovered

0041A	Novavax COVID-19 First Dose - immunization administration intramuscular 5 mcg/0.5 mL
0042A	Novavax COVID-19 Second Dose - immunization administration intramuscular 5 mcg/0.5 mL
91305	Pfizer-BioNTech COVID-19 Vaccine 30 mcg/0.3 mL
0051A	Pfizer-BioNTech COVID-19 First Dose - administration
0052A	Pfizer-BioNTech COVID-19 Second Dose - administration
0053A	Pfizer-BioNTech COVID-19 Third Dose - administration
0054A	Pfizer-BioNTech COVID-19 Booster - administration
91306	mRNA-LNP 50 mcg/0.25 mL dosage vaccine
0064A	50 mcg/0.25 mL booster administration
91307	Pfizer-BioNTech COVID-19 Pediatric Vaccine 10 mcg/0.2 mL

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Reimbursable administrations & limits

Reimbursable administrations per dayUp to 15 administrations per day

Shingles vaccine limit2 per lifetime

HPV vaccine limit3 per lifetime

Pediatric dosing examples

Pfizer pediatric formulations10 mcg/0.2 mL and 3 mcg/0.2 mL pediatric formulations (codes 91307/0071A–0074A and 91308/0081A–0083A)

Moderna pediatric formulation25 mcg/0.25 mL pediatric formulation (code 91311/0111A–0013A)

Provider Responsibilities, Billing, and Documentation

Prior Authorization

Eligibility, Prior Authorization, and Billing

Providers must verify member eligibility, coverage and any required prior authorization before rendering services. All services must be medically necessary to qualify for reimbursement. Neighborhood may use NCDs, LCDs, InterQual, Rhode Island EOHHS guidance, and Neighborhood Clinical Medical Policies when determining medical necessity.

Verify eligibility and benefits prior to the date of service
Confirm prior authorization requirements on Neighborhood's Prior Authorization Reference page
Obtain and document any required prior authorizations before providing services

Billing Rule

Claim Submission & Timely Filing

Key Definitions

State‑supplied vaccines (DOH)

State-supplied vaccine costVaccines provided by the Rhode Island Department of Health (DOH) are supplied at no cost to providers and Neighborhood will not reimburse the vaccine product charge

Administration coverageAdministration charges for state-supplied vaccines are covered and reimbursed when billed

Billing requirement for dataProviders should bill vaccine CPT codes for data collection even if the vaccine product is not reimbursed

Primary care (PCP) site definitions

Acceptable PCP locationsPhysician's office, hospital outpatient department, community health center

School-based sitesSchool-based health centers are treated as PCP sites for immunization and vaccine administration

Background and Purpose

Immunizations and vaccinations are a key public health intervention to prevent infectious disease. This policy covers immunizations when they are medically necessary and aligns coverage with the Rhode Island Department of Health State Supplied Vaccine Schedule and CDC recommendations. Neighborhood will reimburse for administration of covered vaccines and follows plan governance for additional vaccines approved by the Clinical Management Committee. Providers should note that state-supplied vaccine product charges may not be reimbursed when the vaccine is provided at no cost through public programs, but administration charges are reimbursable when the other coverage criteria are met.

Document History

2023-01-01policy_reviewLatest

Updated COVID vaccine/administration table to include new codes; removed language under INTEGRITY COVID section about billing original Medicare and reimbursement by NHP.

2021-11-12policy_update

Combined COVID Vaccine Payment Policy with Immunization and Vaccine Payment Policy; added pediatric COVID vaccine and administration codes and Moderna and Janssen booster codes; updated Integrity member requirements effective 01/01/2022.

2021-05-25