Newborn Metabolic, Endocrine and Hemoglobinopathy and the Newborn Hearing Loss Screening Programs Mandate
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Mandated Rhode Island coverage guidance requiring newborn metabolic, endocrine, hemoglobinopathy, and hearing loss screening; applies to applicable commercial health plans and providers performing newborn screening in Rhode Island.
No material clinical or coverage changes in this revision.
Coverage Criteria for Newborn Screening
Mandated Newborn Screening
Covered when performed as part of the Rhode Island-mandated newborn screening programs and consistent with state regulations:
Mandated screening
- Conditions list: Screening must include the disorders enumerated by the State (examples include amino acid, organic acid, fatty acid oxidation disorders, hemoglobinopathies, biotinidase deficiency, congenital adrenal hyperplasia, congenital hypothyroidism, cystic fibrosis, galactosemia, SCID [effective 8/1/2014], and critical congenital heart disease [effective 7/1/2015]).
Full list and effective dates are specified in Section 2.1 and 2.1 (Others).
See Sections 2.2 and 2.3.1.
See Section 2.3.2 for reporting requirements.
Coverage and Payment
Coverage and payment responsibilities:
See Section 5.1 and 5.2.
See Sections 5.3 and 5.4.
See Coverage section and provider benefit documents.
Newborn hearing screening
Covered services:
See Section 3.1 and 'Newborn Hearing Loss Screening Program' statement.
The attending physician and/or midwife shall not perform newborn screening tests when the newborn's parents expressly object on religious grounds. This religious exemption applies to the mandated metabolic, endocrine, hemoglobinopathy, and hearing screening programs and is authorized by Rhode Island statute; when an objection is asserted, the tests shall not be performed.
Coverage and payment for medically necessary services described in this policy are subject to the member's subscriber agreement, member certificate, or the employer agreement, which supersede this medical policy. Providers must verify member-specific benefits and eligibility through the provider call center; services that are determined to be not medically necessary or that are medically necessary but defined as non-covered benefits under the member's contract may not be chargeable to the member unless the member was informed and provided written agreement in advance to accept financial responsibility.
Billing and Coding
Provider Responsibilities and Billing Guidance
Prior authorization and billing — No prior authorization; DOH lab billing
No prior authorization is required for Rhode Island–mandated newborn screening; these programs are covered services for Commercial Products. The Department of Health laboratory submits claims using the unlisted code used for newborn screening (84999-32).
- Newborn screening programs are covered services for Commercial Products.
- Department of Health laboratory uses unlisted billing code 84999-32 for newborn screening claims.
Prior authorization — Verify per-member benefits for hearing screening
Hearing screenings are listed as covered services; the policy does not specify prior authorization requirements, so providers must verify member-specific prior authorization rules and coverage via benefit verification.
- Hearing screenings are covered services.
- Verify member-specific prior authorization and coverage through the provider call center or benefit booklet.
Step therapy — Not applicable
Step therapy is not applicable to these mandated newborn screening services.
Provider action — None specified
No additional provider action specified in the policy text.
Lab reporting requirements — Submit complete lab reports to physician and Department
Laboratory reports of newborn screening tests must be submitted to the attending physician and to the Department and must include the actual measured values and the reference ranges used for each disorder.
- All laboratory reports for newborn screening must include actual values and reference ranges used for each disorder.
- Reports must be submitted to the attending physician and to the Department.
Case reporting — Report confirmed cases and required data within 90 days
Each confirmed newborn screening diagnosis must be reported to the Department's Newborn Screening Program within 90 days and must include the diagnostic test type, treatment type, and any additional information the Director requires.
- Report confirmed diagnosis, diagnostic test type, treatment type, and Director-required data.
- Submit confirmed-case data within ninety (90) days of confirmation to the Department's Newborn Screening Program.
Verify member benefits and eligibility — Use provider call center
Providers must verify member-specific benefits and eligibility through the provider call center because benefits are determined by the member's subscriber agreement or employer agreement, which supersede this policy.
- Call the provider call center for member-specific benefits and eligibility.
- Member subscriber/employer agreements determine benefits and supersede this policy.
Coverage varies by contract — Verify contract-specific mandates
Benefits and coverage may vary between groups and contracts; Rhode Island–mandated benefits do not apply to BlueCHiP for Medicare and self-funded groups may choose not to follow state mandates, which can result in noncoverage.
- Refer to the Benefit Booklet, Evidence of Coverage, or Subscriber Agreement for applicable laboratory and hearing benefits.
- BlueCHiP for Medicare and some self-funded groups may not be subject to state mandates.
Financial liability — Do not charge member for NMN/non-covered services without written consent
If a service is determined to be not medically necessary or is a medically necessary service that is a non-covered benefit, the provider may not charge the member unless the member has been informed in advance and has agreed in writing to pay for the service.
- Do not bill the member for NMN or non-covered services unless written informed consent/waiver is obtained in advance.
- Refer to participation and subscriber agreements for applicable provisions.
Background
Newborn screening tests are performed to detect disorders that are not clinically apparent at birth, including metabolic, endocrine, hemoglobinopathy conditions and hearing loss. Early identification through heel-prick blood screening and newborn hearing evaluation enables prompt diagnosis and intervention to prevent death or disability and is mandated by Rhode Island law unless a parental religious exemption is asserted.
Definitions
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