CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Non-Covered Services Payment Policy – Archive 14

Defines services, supplies, devices, and circumstances that Neighborhood Health Plan of Rhode Island considers non-covered across Medicaid (excluding EFP), INTEGRITY, and Commercial lines of business. Provides examples and categories of exclusions, investigational/experimental criteria, DME rules, cosmetic exclusions, infertility exclusions, and other general non-covered items; links to external code grids for plan-specific non-covered CPT/HCPCS/ICD-10/modifiers.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyNon-Covered Services Payment Policy – Archive 14

Policy CodePolicy N/A

Change TypeMultiple revisions and additions (coding grid updates, exclusions added)

Effective DateFeb 28, 2017

Next Review Date

Key ActionCheck plan prior authorization requirements; prior authorization is recommended for certain donor/ART drug and donor-related infertility services.

SourceLink

POLICY UPDATE CHANGES

07/01/24 Policy Updated: additional codes added/removed from CPT/HCPC list.

03/11/24 Policy Updated: additional codes added/removed from CPT/HCPC list, added surrogate language to Medicaid section.

11/28/23 Policy Updated: additional codes added/removed from CPT/HCPC list.

09/05/23 Added services to Additional Coverage Exclusions for all LOB and removed abortion services exclusion for all LOB.

03/29/23 Added Concierge Services for all LOB, converted code lists to external link, added GC modifier to Commercial.

02/15/21 Added language to cosmetic services for Medicaid and Integrity; medical marijuana added to exclusions.

02/28/17 Policy Effective Date

~100+Explicit listed non-covered items/entries

1External coding grid link

Coverage Summary & Scope

This is an informational payment policy from Neighborhood Health Plan of Rhode Island that documents coverage exclusions and non-covered services. It is CURRENT and applies to the following lines of business: Medicaid (excluding EFP), INTEGRITY, and Commercial. Claim payment and reimbursement are subject to plan benefits, member eligibility, authorization requirements, coding and documentation rules, provider contract terms, and state and federal laws. Plan-specific non-covered CPT/HCPCS/ICD-10/Modifier listings are provided via an external coding grid at the plan website.

Key Policy Facts

PayerNeighborhood Health Plan of Rhode Island

Policy TitleNon-covered Services and Payment Exclusions

Policy Number

Effective Date2017-02-28

Last Review2024-07-01

LOBs referencedMedicaid (excluding EFP), INTEGRITY, Commercial

External Code Grid Linkhttps://www.nhpri.org/providers/policies-and-guidelines/billing-guidelines-and-payment-policies/

Medical-Necessity / Non-Covered Criteria

Dental Exclusions

Non-covered dental services:

ANY of the following

Orthodontia
All dental services except emergency/limited oral surgery: All dental services other than emergency dental and limited oral surgery are not covered
Adult preventive and restorative services (routine exams, X-rays, cleanings, tooth extractions, fillings, implants) are not covered

Coding & External Code Grids

External non-covered code grids (CPT/HCPCS/ICD-10/Modifiers)mixed

external_link

Plan-specific listings of non-covered CPT, HCPCS, ICD-10 and Modifiers available at https://www.nhpri.org/providers/policies-and-guidelines/billing-guidelines-and-payment-policies/ (detailed external CPT/HCPCS/ICD-10/modifier lists are maintained on the payer website/spreadsheet).

Provider Actions & Billing Impact

Prior Authorization

Prior authorization recommended for some infertility donor/ART services

Prior authorization is recommended for drugs for anonymous or designated egg donors that are directly related to a stimulated ART cycle and for certain donor-related infertility services. Check the plan's prior authorization requirements before providing donor drug services or donor-related infertility services.

Documentation Required

Documentation required for replacement of stolen/destroyed DME

To request replacement of DME that has been stolen or destroyed, providers must submit documentation including an explanation of continuing medical necessity for the item, an explanation that the item was stolen or destroyed, and, if applicable, a copy of a police, fire department, or insurance report.

Background & Definitions

This policy is an informational listing of exclusions and non-covered services and should not be considered exhaustive or a guarantee of reimbursement. Neighborhood may update the policy at any time and reserves the right to cover certain non-covered services under pilot programs. Claims for services listed as non-covered remain subject to member benefits, eligibility, required authorizations, coding and documentation rules, provider contract agreements, and applicable state and federal laws. For plan-specific code listings (non-covered CPT, HCPCS, ICD-10 and Modifiers) see the external non-covered code grids linked on the Neighborhood provider policies webpage.

Definitions

Note

Revision History & Policy Updates

07/01/24revisedLatest

07/01/24 Policy Updated: additional codes added/removed from CPT/HCPC list.

03/11/24revised

03/11/24 Policy Updated: additional codes added/removed from CPT/HCPC list, added surrogate language to Medicaid section.

11/28/23revised

11/28/23 Policy Updated: additional codes added/removed from CPT/HCPC list.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyNon-Covered Services Payment Policy – Archive 14

Policy CodePolicy N/A

Change TypeMultiple revisions and additions (coding grid updates, exclusions added)

Effective DateFeb 28, 2017

Next Review Date

Key ActionCheck plan prior authorization requirements; prior authorization is recommended for certain donor/ART drug and donor-related infertility services.

SourceLink

On This Page

Billing Rule

Network provider requirement

Services must be rendered by network providers unless it is an emergency or prior approval has been received. Services provided in nonconventional settings are excluded. Claims for non-network services provided without prior approval may be denied.

Denial Risk

Claims subject to denial if non-covered

Claims for services, supplies, devices, or settings listed as non-covered (for example cosmetic procedures, alternative/complimentary therapies, specified DME and home items, infertility services and donor-related costs, and other items enumerated in the policy) are subject to denial and are not payable under the plan unless otherwise specified by covered services or required by law.

09/05/23added

09/05/23 Added services to Additional Coverage Exclusions for all LOB and removed abortion services exclusion for all LOB.

03/29/23revised

03/29/23 Added Concierge Services for all LOB, converted code lists to external link, added GC modifier to Commercial.

02/15/21added

02/15/21 Added language to cosmetic services for Medicaid and Integrity; medical marijuana added to exclusions.

02/28/17added

02/28/17 Policy Effective Date