CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Dialysis Services 10.03.13 Through 09.30.21

Defines coverage of dialysis (hemodialysis and peritoneal dialysis), including biologicals, injectable drugs administered as part of dialysis, and supplies for specified Medicaid/managed care benefit packages; notes exclusions and referral to inpatient/outpatient surgical benefits for catheter insertion.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyDialysis Services 10.03.13 Through 09.30.21

Policy CodePolicy N/A

Change TypeClarified (revision metadata only)

Effective DateN/A

Next Review DateN/A

Key ActionVerify member enrollment in one of the covered benefit packages (RIte Care, Substitute Care, Children with Special Health Care Needs, Rhody Health Partners, Rhody Health Options Phase One) before providing dialysis services.

SourceLink

POLICY UPDATE CHANGES

PEC Revision date recorded as 10/3/13; publication date 09/01/10.

5Covered Benefit Packages

1Explicit Exclusion (EFP)

Coverage Summary

Overview: This policy defines coverage for dialysis (hemodialysis and peritoneal dialysis), including related biologicals, injectable drugs administered as part of dialysis, and necessary supplies for members enrolled in specified Medicaid/managed care benefit packages. Status: CURRENT; Coverage stance: covered_with_criteria. Covered Benefit Packages: 5. Explicit Exclusion: Extended Family Planning (EFP) — 1.

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Medically Necessary / Exclusions

Catheter Insertion Procedures

Operational note:

Catheter Insertion Procedures: Catheter insertion (A-V fistula creation, peritoneal catheter placement, etc.), whether inpatient or outpatient, is covered under the respective inpatient or outpatient surgical benefit coverage summaries (not under this dialysis benefit policy).

Refer to respective surgical benefit coverage summaries for coverage criteria and billing.

Provider Actions & Billing Rules

Documentation Required

Benefit package verification

Verify member enrollment in one of the covered benefit packages before providing dialysis services.

RIte Care
Substitute Care
Children with Special Health Care Needs
Rhody Health Partners
Rhody Health Options Phase One

Billing Rule

Catheter insertion billing pathway

Bill catheter insertion procedures (for example, A-V fistula creation or peritoneal catheter placement) under the applicable inpatient or outpatient surgical benefit coverage summaries rather than under the dialysis services benefit.

A-V fistula example
Peritoneal catheter example

Denial Risk

EFP members excluded

Claims for dialysis services for members enrolled in Extended Family Planning (EFP) may be denied.

EFP members do not have a comprehensive benefit package that includes dialysis.

Definitions & Background

Background: Dialysis is defined as an artificial replacement for lost kidney function due to acute or chronic renal failure; hemodialysis and peritoneal dialysis sessions are covered for the listed benefit packages. ESRD is considered a permanent condition for which dialysis is provided unless a kidney transplant occurs. Members with ESRD who qualify for Medicare may become eligible after three months of dialysis and can transition to dual Medicare/Medicaid eligibility.

Term	Definition
Dialysis
An artificial replacement for lost kidney function due to acute or chronic renal failure. Hemodialysis and peritoneal sessions are covered for the benefit packages listed.
ESRD
End Stage Renal Disease; dialysis is provided to members with ESRD which is considered a permanent condition unless kidney transplant occurs.
Benefit Packages
RIte Care, Substitute Care, Children with Special Health Care Needs, Rhody Health Partners and Rhody Health Options Phase One.