Who we serve · Pediatrics
Pediatric practices. Every dose, every well visit, billed to the plan that owes it.
Enrollment, billing and denials for an independent pediatric practice are what HRI Med offers, built on the claim and denial work HRI does for behavioral-health facilities. We enroll the practice and every pediatrician and nurse practitioner with Medicaid, each managed-care plan and the commercial plans families carry, then bill the vaccines, well visits and sick visits to each plan's rules.
Medicaid plans, vaccine stock and the same-day visit.
A pediatric practice bills Medicaid and CHIP beside the commercial plans parents get through work. In many states Medicaid pays through managed-care plans, and federal rules require each plan's network providers to be enrolled with the state as well.A One pediatrician can need the state, then each plan.
Practices registered with Vaccines for Children receive that stock free, so for a Medicaid child the practice is paid an administration fee, capped at a ceiling set for each state, and nothing for the dose. Children in a separate CHIP program are not eligible for those doses.B Each child's coverage decides which stock a dose comes from.
Administration is reported with CPT 90460 and 90461 or with 90471 to 90474, depending on the child's age and whether the physician counseled the family. When a sick visit happens on the same day as the shots, it is billed only if it is significant and separately identifiable, with modifier 25.C
A well visit that turns sick is paid by each plan's own rule. UnitedHealthcare's commercial policy pays the preventive visit plus 50% of the problem-oriented visit when modifier 25 is attached, and nothing for the problem visit without it.D We record each plan's version.
Newborns are seen before they have a member ID of their own. A baby born to a mother on Medicaid is covered from birth without an application.E A commercial plan waits for the parents to add the baby. We confirm coverage before those first claims go out.
Well-child visits and recommended immunizations are generally covered at no cost to the family when an in-network provider delivers them, and Medicaid's EPSDT benefit covers preventive care for enrolled children under age 21.B, F Both only work for a practice the plan has on file.
Enrollment first, then the claims a busy clinic makes.
- Enrollment
- The practice and every pediatrician and nurse practitioner, with Medicaid, CHIP and each managed-care plan, and the commercial plans on your list, each tracked to an effective date.
- Eligibility
- Coverage checked before the visit, including newborns, so each dose and each visit goes to the plan that owes it.
- Claims and posting
- Vaccine, well-visit and sick-visit claims built to each plan's rules, and payments matched to what it owes.
- Denials
- Traced to the cause and fixed at the source, so the same modifier or eligibility error is less likely to recur.
| Piece of work | Fee |
|---|---|
| The practice, with each payer | $350 |
| Each pediatrician or NP, with each payer | $250 |
| A clinician's CAQH ProView profile (CAQH now operates as DataSpring), built or repaired | $150 |
| Billing and the revenue cycle | By agreement |
Total your own enrollment with the calculator.
Common questions from pediatric practices.
We are opening a pediatric practice. Which plans come first?
The ones the families you expect already carry, which often means Medicaid, its managed-care plans and a few large commercial plans. Each takes one practice application at $350.
Do you bill Vaccines for Children doses?
Yes. We bill the administration fee for those doses and both the vaccine and its administration for privately bought stock, matched to each child's coverage.
Our well visits with a sick complaint get paid as one visit. Why?
Usually a missing modifier 25, or notes that do not show a separate service. We find the pattern, fix it at the source and appeal what is still owed. How billing runs
Sources
- 42 CFR 438.602(b), managed-care network providers. Read 2026.
- CMS, vaccine coverage and payment under Medicaid and CHIP. Read 2026.
- CMS, Medicaid NCCI Policy Manual, Chapter XI. Read 2026.
- UnitedHealthcare, commercial Preventive Medicine and Screening Policy. Read 2026.
- 42 CFR 435.117, deemed newborn children. Read 2026.
- HealthCare.gov, preventive care for children. Read 2026.
Send us your pediatricians and the plans your families carry.
We check each plan against your enrollment and tell you which ones are missing. The review needs no patient information.
Include the Medicaid and CHIP plans your families carry as well as the commercial ones.