Deemed Eligibility Coverage Reminders
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Reminds providers caring for members enrolled in Neighborhood INTEGRITY for Duals (HMO DSNP) or Neighborhood Dual CONNECT (HMO D-SNP) about coverage, reimbursement, verification, and authorization practices during temporary deemed Medicaid eligibility periods.
No material clinical or coverage changes in this revision.
Deemed Eligibility Coverage and Claims Handling
Deemed eligibility coverage criteria
Rules governing coverage, verification, claims adjudication, and actions when Medicaid is restored.
ALL of the following
Deemed period (product-specific)
- INTEGRITY for Duals: deemed eligibility period up to 90 days from the 'Effective To' date.
- Dual CONNECT: deemed eligibility period up to 30 days from the 'Effective To' date.
ALL of the following
- Authorizations: Do not submit new authorization requests for Medicaid-covered services during a member's deemed eligibility period.
- Pre-existing authorizations: An authorization decision made before a member enters a deemed eligibility period does not guarantee payment for services rendered during the deemed eligibility period.
ALL of the following
- Claims adjudication: Claims are adjudicated based on the member's eligibility status on the date of service; services requiring active Medicaid eligibility rendered during deemed eligibility will deny.
- If Medicaid eligibility is later restored: Neighborhood will work to help restore eligibility and will adjust impacted claims accordingly if eligibility is restored.
Impacted Services and Deeming Time Windows
| No codes listed |
Authorization and Billing Guidance for Providers
Do not submit new authorizations during deemed eligibility
Do not submit new authorization requests for Medicaid-covered services while a member is in a deemed eligibility period. Prior authorization decisions made before a member enters a deemed eligibility period do not guarantee payment for services rendered during that period; claims are adjudicated based on the member’s eligibility on the date of service and services requiring active Medicaid eligibility rendered during deemed eligibility will deny.
- Verify deeming status using the Rhode Island Medicaid Health Care Portal before rendering services and before submitting claims.
- Neighborhood will not issue a separate provider notification each time a member enters deemed eligibility; providers must proactively check eligibility.
Key Definitions
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