CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Adult Day Health Services — Coverage Criteria

Defines coverage and authorization requirements for Adult Day Health Services for Neighborhood Health Plan of Rhode Island members in specified RI Medicaid benefit packages.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyAdult Day Health Services — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJul 1, 2013

Next Review DateN/A

Key ActionObtain prior authorization for RIte Care and Rhody Health Partners members.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

7/1/2013In-plan

3Benefit packages

RIte Care/RhodyAuth required

Coverage Criteria for Adult Day Health Services

General Coverage Criteria

Covered when ALL of the following are met

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyAdult Day Health Services — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJul 1, 2013

Next Review DateN/A

Key ActionObtain prior authorization for RIte Care and Rhody Health Partners members.

SourceLink

On This Page

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.

Provider Requirements and Authorization

Prior Authorization

Prior Authorization Required

Prior authorization is required for RIte Care and Rhody Health Partners members.

Applies to RIte Care and Rhody Health Partners members.
Not required for Rhody Health Options Phase One when a comprehensive plan of care is in place.

Denial Risk

Authorization Requirement / Denial Risk

Failure to obtain required prior authorization for RIte Care and Rhody Health Partners members may result in denial of coverage.

Denial risk applies when services are provided without prior authorization where required.

Billing Rule

Billing and Care Plan Notes

Providers should follow in‑network contract billing guidelines and maintain a comprehensive plan of care for Rhody Health Options Phase One members.

Follow in‑network contract billing guidelines for claims submission.
For Rhody Health Options Phase One members, ensure a comprehensive plan of care is documented and maintained.

Documentation Required

Provider Actions Summary

Providers must obtain prior authorization where required and document the member's plan of care; follow contract billing rules and verify member benefit package (RIte Care, Rhody Health Partners, Rhody Health Options Phase One).

Benefit packages affected: RIte Care, Rhody Health Partners, Rhody Health Options Phase One.
Adult Day Health Services became an in‑plan benefit effective 2013-07-01 — verify eligibility.
Maintain documentation of authorization and comprehensive plan of care to support medical necessity and billing.

Key Definitions

inv-08: Adult Day Health program — definition of the program and services provided.

DefinitionA comprehensive, nonresidential program designed to address the biological, psychological, and social needs of adults through individual plans of health that incorporate, as needed, a variety of health, social and related support services in a protective setting.

Services includedNursing care, therapies, personal care assistance, social and recreational activities, meals, and other services in a community group setting.

Target populationFrail seniors and other adults who need supervision and health services during the daytime and who return to their homes and caregivers at the end of the day.

Program settingNonresidential, supervised daytime group program (Adult Day Health program).

Covered benefit packagesBenefit Packages: RIte Care, Rhody Health Partners, and Rhody Health Options Phase One.

Background and Program Overview

Adult Day Health Services are nonresidential, supervised daytime programs for frail seniors and adults who require supervision and health services but are able to return home at the end of the day. Services typically include nursing care, therapies, personal care assistance, social and recreational activities, meals, and an individualized plan of health to address biological, psychological, and social needs.