CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Payment Policy Early Intervention Services Mandate

Defines coverage, billing codes, modifiers, and administrative rules for Rhode Island Early Intervention services for commercial products covering children from birth to age 3 who are Rhode Island residents.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyPayment Policy Early Intervention Services Mandate

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date01/01/2014

Next Review DateN/A

Key ActionPrior authorization review is not required.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

birth–3age range covered

$5,000annual per-child benefit limit

Noneprior authorization

Commercialapplicability

11/15/2023policy last updated

Coverage criteria and administrative rules

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Coverage criteria and rules

Commercial product coverage rules and limitations for Rhode Island Early Intervention services

Members must be Rhode Island residents age birth to 3 who are certified by the Department of Human Services as eligible for Early Intervention services.

Coverage is limited to $5,000 per dependent child per policy or calendar year and shall not be subject to deductibles and coinsurance factors.

Insurers shall reimburse certified early intervention providers at rates of reimbursement to or greater than the prevailing integrated state Medicaid rate for early intervention services as established by the Department of Human Services.

Product exceptions

RI‑mandated benefits generally do not apply to Plan 65, FEHBP, and Medicare Advantage plans.
Groups that are self‑insured may choose not to comply with state mandates; refer to the member certificate/subscriber agreement for coverage specifics.

Benefits may vary between groups and contracts; refer to the appropriate Benefit Booklet, Evidence of Coverage, or Subscriber Agreement for applicable Early Intervention benefits/coverage.

Early Intervention services include speech and language therapy, occupational therapy, physical therapy, evaluation, case management, nutrition, service plan development and review, nursing services, and assistive technology services and devices.

Service setting and nature

Services may be remedial or preventive in nature.
Services may be provided in center‑based, home‑based, hospital‑based, or other settings.

Claims must be filed with correct modifiers and place‑of‑service codes (e.g., EP modifier and telephone/telemedicine POS as specified per code); refer to code‑specific modifier guidance for billing.

COVID‑19 telehealth delivery guidance applies (effective March 18, 2020 until further notice); refer to EOHHS guidance and coding/billing modifiers for telehealth/telephone services.

Prior authorization is not required for these services.

Early Intervention Services administrative and billing guidance

Guidance and administrative notes pertaining to Early Intervention Services for commercial products.

For current information on allowed units and specific billing rules, providers should refer to the Rhode Island Department of Health Services Claims section (Early Intervention Programs).

Benefits may vary between groups and contracts; providers must consult the member's Benefit Booklet, Evidence of Coverage, or Subscriber Agreement for member‑specific benefit determinations.

This medical policy is informational and is not a guarantee of payment; benefits and eligibility are determined by the member's subscriber agreement, member certificate, and/or employer agreement, which supersede this policy.

Providers may not bill members for services determined to be non‑covered or not medically necessary unless the provider has informed the member and the member has agreed in advance to continue treatment at their own expense; refer to participation agreements for applicable provisions.

Billable codes, modifiers, and limits

Early Intervention billable codes and telehealth modifiersmixedCovered

92522	Evaluation of speech sound production (articulation, phonological process, apraxia, dysarthria); append modifier 52 for reduced services; Applicable Modifier(s) = EP; telephone only POS 02 or POS 10 and Modifier FQ; telemedicine POS 02 or POS 10 and Modifier 95.
92523	Evaluation of speech sound production with evaluation of language comprehension and expression (receptive and expressive language); append modifier 52 for reduced services; Applicable Modifier(s) = EP; telephone only POS 02 or POS 10 and Modifier FQ; telemedicine POS 02 or POS 10 and Modifier 95.
92557	Comprehensive audiometry threshold evaluation and speech recognition; Applicable Modifier(s) = EP; telephone only POS 02 or POS 10 and Modifier FQ = N/A; telemedicine POS 02 or POS 10 and Modifier 95 = N/A.
96111	Developmental testing with interpretation and report (assessment of motor, language, social, adaptive, and/or cognitive functioning by standardized developmental instruments); Applicable Modifier(s) = EP; telephone only POS 02 or POS 10 and Modifier FQ = N/A; telemedicine POS 02 or POS 10 and Modifier 95 = N/A.
97161	Physical therapy evaluation: low complexity; Applicable Modifier(s) = EP; telephone only POS 02 or POS 10 and Modifier FQ = N/A; telemedicine POS 02 or POS 10 and Modifier 95 = N/A.
97162	Physical therapy evaluation: moderate complexity; Applicable Modifier(s) = EP; telephone only POS 02 or POS 10 and Modifier FQ = X; telemedicine POS 02 or POS 10 and Modifier 95 = X.
97163	Physical therapy evaluation: high complexity; Applicable Modifier(s) = EP; telephone only POS 02 or POS 10 and Modifier FQ = (as listed); telemedicine POS 02 or POS 10 and Modifier 95 = (as listed).
97164	Re-evaluation of physical therapy; Applicable Modifier(s) = EP; telephone only POS 02 or POS 10 and Modifier FQ = X; telemedicine POS 02 or POS 10 and Modifier 95 = (as listed).
97165	Occupational therapy evaluation: low complexity; Applicable Modifier(s) = EP; telephone only POS 02 or POS 10 and Modifier FQ = X; telemedicine POS 02 or POS 10 and Modifier 95 = (as listed).
97166	Occupational therapy evaluation: moderate complexity; Applicable Modifier(s) = EP; telephone only POS 02 or POS 10 and Modifier FQ = X; telemedicine POS 02 or POS 10 and Modifier 95 = (as listed).

1–10 of 19

1/2

Units referencemixed

No codes listed

inv-05: Annual benefit limit per child — $5,000

Annual benefit limit per dependent child$5,000 per dependent child per policy or calendar year; not subject to deductibles or coinsurance and not applied to other annual or lifetime maximums.

Applicability age rangeDependent children from birth to age 3 who are certified by the Department of Human Services as eligible for services.

Reimbursement requirementInsurers shall reimburse certified early intervention providers at rates equal to or greater than the prevailing integrated state Medicaid rate as established by the Department of Human Services.

Definitions and general policy notice

inv-08: Early Intervention services

DefinitionServices promoting the development of infants and toddlers with developmental delays and challenges, delivered individually or with family involvement; may be remedial or preventive.

Included service typesSpeech and language therapy, occupational therapy, physical therapy, evaluation, case management, nutrition, service plan development and review, nursing services, and assistive technology services and devices.

Settings and scopePrograms may be center-based, home-based, hospital-based, or other combinations and may begin any time up to the child turning three years of age.

inv-09: General policy notice

Informational natureThis medical policy is made available for informational purposes only and is not a guarantee of payment or a substitute for medical judgment.

Benefits and eligibilityBenefits and eligibility are determined by the member's subscriber agreement, member certificate, and/or employer agreement; those documents supersede this policy.

Provider billing responsibilityIf services provided are determined to be non-covered, providers may not bill the member unless the member was informed and agreed in advance to continue treatment at their own expense; refer to participation agreements.

OpenPayer

Payment Policy Early Intervention Services Mandate

Coverage criteria and administrative rules

Billable codes, modifiers, and limits

Provider obligations and billing notes

Definitions and general policy notice