CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

COVID-19 vaccine coverage and reimbursement

Governs Neighborhood Health Plan of Rhode Island's coverage and reimbursement requirements for COVID-19 vaccines and vaccine administration for Medicaid (including EFP), INTEGRITY, and Commercial members; directs provider billing and documentation obligations.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyCOVID-19 vaccine coverage and reimbursement

Policy CodePolicy N/A

Change TypeClarified languageCodes added (non-material)

Effective DateDec 11, 2020

Next Review DateN/A

Key ActionVerify eligibility, coverage and authorization criteria prior to rendering services; contact Provider Services at 1-800-963-1001.

SourceLink

POLICY UPDATE CHANGES

Language regarding billing of vaccine was updated.

Policy updated with new vaccine and administration codes 91303 and 0031A effective 2/27/21.

3Vaccines named

91300,91301,91303Vaccine CPT codes

0001A,0002A,0011A,0012A,0031AAdministration codes

No vaccine product reimbursementProduct reimbursement

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COVID-19 Vaccine Coverage Criteria

COVID-19 vaccine and administration coverage criteria

Covered when meeting FDA/CDC guidance; specific reimbursement rules apply for vaccine product and administration.

Policy applies to FDA-approved and CDC-recommended COVID-19 vaccines, including vaccines authorized under Emergency Use Authorization, and to administration of those vaccines during the Rhode Island COVID-19 State of Emergency.

ALL of the following

Vaccine product codes will not be reimbursed because vaccines are provided at no cost to providers through the federal government; providers must still bill vaccine CPT product codes for data collection.

ALL of the following

Vaccine administration codes will be covered and separately reimbursed according to the codes identified in this policy.

ALL of the following

Neighborhood will waive member cost share for Commercial plans for all FDA EUA-approved and CDC-recommended COVID-19 vaccines and administration services; providers should not collect any cost-share for the vaccine or administration.
If the primary purpose of the office visit is delivery of the recommended COVID-19 immunization, no member cost share should be applied to the visit.

ALL of the following

Providers must bill Original Medicare for Integrity members for vaccine and administration services provided in 2020 and 2021; claims submitted to Neighborhood for these members will be denied.

ALL of the following

Neighborhood may request medical records; documentation must support billed services and medical necessity and follow applicable standards.

Coding and Reimbursement Details

Covered COVID-19 vaccine CPT codesCPTCovered

91300	Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 30 mcg/0.3mL dosage, diluent reconstituted, for intramuscular use. Pfizer-BioNTech COVID-19 Vaccine.
91301	Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 100 mcg/0.5mL dosage, for intramuscular use. Moderna COVID-19 Vaccine.
91303	Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, DNA, spike protein, adenovirus type 26 (Ad26) vector, preservative free, 5x10^10 viral particles/0.5mL dosage, for intramuscular use. Johnson & Johnson COVID-19 Vaccine.

Covered COVID-19 vaccine administration codesCPT | HCPCSCovered

0001A	Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 30 mcg/0.3mL dosage, diluent reconstituted; Pfizer-BioNTech COVID-19 First Dose.
0002A	Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 30 mcg/0.3mL dosage, diluent reconstituted; Pfizer-BioNTech COVID-19 Second Dose.
0011A	Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 100 mcg/0.5mL dosage; Moderna COVID-19 First Dose.
0012A	Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 100 mcg/0.5mL dosage; Moderna COVID-19 Second Dose.
0031A	Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, DNA, spike protein, adenovirus type 26 (Ad26) vector, preservative free, 5x10^10 viral particles/0.5mL dosage, single dose; Johnson & Johnson Administration.

Vaccine product reimbursement status

Reimbursement statusVaccine product codes will not be reimbursed because vaccines are provided at no cost to providers through the federal government.

Billing requirementProviders must continue to bill vaccine CPT product codes for the purposes of data collection even though product codes are not reimbursed.

Administration reimbursementVaccine administration codes will be covered and separately reimbursed according to the administration codes identified in this policy.

Applicable plansPolicy statement applies to Medicaid and Commercial members during the Rhode Island COVID-19 State of Emergency.

Provider Billing and Eligibility Actions

Prior Authorization

Prior verification — confirm eligibility, coverage and authorizations before service

It is the provider's responsibility to verify member eligibility, coverage and any required authorization PRIOR to rendering services; refer to Neighborhood's plan-specific Prior Authorization Reference page and Clinical Medical Policies for details. Contact Provider Services at 1-800-963-1001 with questions related to this policy.

Denial Risk

Integrity billing — bill Original Medicare; do not bill Neighborhood

Do not bill Neighborhood for Integrity members; per CMS guidance, providers must bill Original Medicare for both the vaccine and administration services for services provided in 2020 and 2021. Claims submitted to Neighborhood for Integrity members will be denied.

Bill Original Medicare for vaccine and administration services for Integrity members for 2020 and 2021.
If a claim is sent to Neighborhood for an Integrity member, it will be denied.

Key Definitions

EUA (Emergency Use Authorization)

DefinitionEmergency Use Authorization (EUA) — FDA process through which certain COVID-19 vaccines were authorized for use prior to full approval; this policy includes vaccines approved through the EUA process.

Examples referencedPolicy lists Pfizer‑BioNTech, Moderna, and Johnson & Johnson vaccines as vaccines under FDA EUA or approval.

ScopeApplies to vaccines meeting FDA guidelines, including those approved through EUA, and to administration of those vaccines during the Rhode Island COVID-19 State of Emergency.

Medically necessary — definition and sources

Medical necessity standardAll services must be medically necessary to qualify for reimbursement.

Sources used to determine medical necessity