CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Dialysis (Hemodialysis and Peritoneal Dialysis) Coverage Criteria

Covers hemodialysis and peritoneal dialysis (including associated biologicals, injectable drugs, and supplies) for eligible Neighborhood Health Plan of Rhode Island members in specified benefit packages; excludes Extended Family Planning members.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyDialysis (Hemodialysis and Peritoneal Dialysis) Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionDocument ESRD status and bill catheter insertion under the applicable surgical benefit when placing dialysis catheters.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2service types covered

Nonecoverage limitations

EFPexplicit exclusions

Listedbenefit packages

Coverage Criteria

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Covered Services: Hemodialysis and peritoneal dialysis services, inclusive of biologicals and injectable drugs administered as part of dialysis, and associated supplies are covered.

Applicable Benefit Packages: Coverage applies to Rhode Island benefit packages (including RIte Care, Substitute Care, Children with Special Health Care Needs, Rhody Health Partners and Rhody Health Options Phase One).

ESRD: Dialysis is provided to members with End Stage Renal Disease (ESRD); ESRD is considered a permanent condition unless a transplant occurs.

Members who qualify for Medicare may transition to dual eligible status after 3 months of dialysis.

Provider Actions & Billing

Prior Authorization

Prior Authorization Not Specified

Prior authorization is not specified in this document. Verify prior authorization requirements with Neighborhood Health Plan of Rhode Island before scheduling dialysis-related procedures or services, as the policy does not state any PA rules.

Note

Provider Billing Action

Ensure that dialysis services (hemodialysis and peritoneal dialysis), related biologicals and injectable drugs administered during dialysis, and supplies are billed under the dialysis benefit for the member's applicable benefit package.

Documentation Required

Documentation & Billing Notes for Catheter Insertions

Document catheter insertions (inpatient or outpatient, AV fistula creation, peritoneal catheter placement) and bill them under the appropriate inpatient or outpatient surgical benefit as indicated; include operative reports, device documentation, and any related supply/drug administration records to support medical necessity and correct coding.

Covered catheter insertions: AV fistula, peritoneal catheter, other dialysis access procedures
Bill under respective inpatient or outpatient surgical benefit coverage summaries
Include operative report and related documentation

Denial Risk

Eligibility Exclusion: EFP Members

Extended Family Planning (EFP) members are excluded from the comprehensive benefit package and therefore are not covered for this dialysis benefit; verify member eligibility and coverage package before providing or billing for services.

EFP members do not have a comprehensive benefit package — dialysis benefit excluded

Definitions

inv-08: Dialysis — definition and covered session types

DefinitionDialysis is an artificial replacement for lost kidney function due to acute or chronic renal failure.

Covered session typesHemodialysis and peritoneal dialysis sessions are covered.

Included itemsCoverage includes biologicals and injectable drugs administered as part of dialysis and supplies as part of the dialysis service.

Applicable benefit packagesCoverage applies to RIte Care, Substitute Care, Children with Special Health Care Needs, Rhody Health Partners, and Rhody Health Options Phase One.

Coverage limitationsNone specified; members are encouraged to utilize network providers.

inv-09: ESRD — End Stage Renal Disease definition and relation to dialysis coverage

Definition of ESRDEnd Stage Renal Disease (ESRD): dialysis is provided to members with ESRD, which is considered a permanent condition unless a kidney transplant occurs.

Medicare eligibility noteMembers who qualify for Medicare with ESRD may become eligible after 3 months of dialysis and may transition to dual eligible status (Medicare and Medicaid).

Relation to dialysis coverageDialysis services are provided to members with ESRD as part of covered benefits in the listed packages.

Exclusion impactMembers in the Extended Family Planning (EFP) program are excluded from the comprehensive benefit package and therefore dialysis is not covered for EFP members.

Background

Dialysis is an artificial replacement for lost kidney function used for acute or chronic renal failure, including End Stage Renal Disease (ESRD). The policy covers both hemodialysis and peritoneal dialysis sessions and associated biologicals and injectable drugs when provided to eligible members in the listed benefit packages. ESRD is considered a permanent condition unless a kidney transplant occurs; members with ESRD may qualify for Medicare after 3 months of dialysis and can transition to dual eligible status.