CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Immunizations and vaccine administration reimbursement

Governs reimbursement and coverage rules for immunizations and vaccine administration for Neighborhood Health Plan of Rhode Island members across Medicaid, INTEGRITY, and Commercial products.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyImmunizations and vaccine administration reimbursement

Policy CodePolicy N/A

Change TypeCoding updatesadded RSV codesremoved obsolete COVID-19 codes

Effective DateN/A

Next Review DateN/A

Key ActionVerify member eligibility, coverage and prior authorization requirements before administering or billing vaccines.

SourceLink

POLICY UPDATE CHANGES

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

Combined COVID Vaccine Payment Policy with Immunization and Vaccine Payment Policy and added pediatric COVID vaccine and admin codes previously.

Removed PCP Requirement for vaccines.

15maximum administrations reimbursable per day

2lifetime limit for shingles vaccine

3lifetime limit for HPV vaccine

Medicaid, INTEGRITY, Commercial

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Coverage Criteria and Limits

Coverage criteria and rules

Vaccines and their administrations are covered with specific limitations and exclusions.

Coverage includes vaccines and administration when administered by an eligible provider (e.g., physician office, hospital outpatient department, pharmacy, community health center).

State‑supplied vaccines: Vaccines provided by the Rhode Island Department of Health (DOH) are supplied at no cost to providers and therefore the vaccine product itself is not reimbursed; administration of those vaccines may be reimbursed.

Influenza: Administration charges for all CDC‑approved influenza vaccines are covered regardless of whether the vaccine is state supplied; Neighborhood will not reimburse providers for the vaccine product when state supplied.

Inclusion note: Inclusion of a code in Neighborhood's vaccine list does not guarantee reimbursement; providers should refer to RI DOH and CDC for state‑supplied vaccine lists.

Limits

Shingles (zoster) vaccines are limited to two (2) doses per member lifetime.
Human papillomavirus (HPV) vaccine is limited to three (3) doses per member lifetime.
Up to fifteen (15) vaccine administrations are reimbursable per member per day.

Exclusions by product line

Medicaid and INTEGRITY members: vaccines and immunizations for travel are not covered (certain travel vaccines may be covered for Commercial members as listed in the coding table).
EFP members: state‑supplied vaccines and corresponding administrations are covered as part of the limited benefit package; all other vaccines/administration charges are non‑covered for EFP.

Billing rule: Vaccine product codes must be billed with corresponding administration codes; administration billed without an associated vaccine code may be denied. Providers must retain documentation to support billed services and medical necessity and Neighborhood may request medical records per policy.

Vaccine and Administration Codes

Selected vaccine product codesCPTCovered

90611	Smallpox and monkeypox vaccine, attenuated vaccinia virus, live, non- replicating, preservative 0.5 mL 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, lyophilized, 0.3 mL for percutaneous use, live
90636	Hepatitis A and hepatitis B vaccine (HepA-HepB), adult, 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	Quadrivalent meningococcal (MPSV4) for subcutaneous use
90736	Zoster (shingles) vaccine (HZV) for subcutaneous injection, live

1–10 of 14

1/2

Commercial 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 and related codesCPTCovered

90460	Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional
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)
90474	Immunization administration by intranasal or oral route; each additional vaccine (single or combination vaccine/toxoid)
90480	Immunization administration by intramuscular injection of SARS-CoV-2 (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
G0010	Vaccine administration (unspecified description in document)
M0201	COVID-19 vaccine administration in-home; reported only once per individual home, per date of service

inv-05: daily administration limit

Daily administration limitUp to fifteen (15) administrations are reimbursable per day.

ScopeApplies to reimbursable vaccine administrations per calendar day per member/provider as stated in policy.

ReferenceSee Coverage Limitations for specific member groups and exceptions.

Provider Responsibilities and Billing Requirements

Prior Authorization

Verify eligibility and prior authorization

Provider must verify member eligibility, coverage benefits and obtain any required prior authorization before rendering services. Neighborhood Health Plan of Rhode Island requires that services be medically necessary to qualify for reimbursement; eligibility and authorization determinations may reference Local Coverage Determinations (LCDs), National Coverage Determinations (NCDs), industry-accepted criteria (for example, InterQual), Rhode Island EOHHS guidance, and Neighborhood Clinical Medical Policies (CMPs). Failure to verify coverage or obtain required prior authorization may result in claim denial or member financial liability.

Verify member eligibility and benefits prior to scheduling and again prior to rendering services.
Confirm whether the service requires prior authorization; if required, obtain approval before providing the service.
Follow plan-specific Prior Authorization Reference page for submission instructions and forms.
Refer to Neighborhood Clinical Medical Policies for coverage criteria and medical necessity requirements.
Contact Provider Services at 1-800-963-1001 for questions regarding authorization or coverage.

Definitions and Notes

inv-07: State-supplied vaccines

DefinitionState vaccines provided by the Rhode Island Department of Health (DOH) are supplied at no cost to providers and practitioners; the vaccine product itself is not reimbursed, though administration may be covered.

Administration coverageAdministration charges for CDC-approved flu vaccines are covered regardless of whether the vaccine is state supplied; this coverage applies only to administration.

Where to verifyRefer to RI DOH and CDC websites for current lists of state-supplied and CDC-approved vaccines.

inv-08: Medically necessary

Medically necessary definitionAll services must be medically necessary to qualify for reimbursement; Neighborhood may use LCDs, NCDs, industry-accepted criteria (e.g., InterQual), RI EOHHS recommendations, and Clinical Medical Policies to determine medical necessity.

Provider responsibility