CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Physician Services (Covered Benefit)

Defines Neighborhood Health Plan of Rhode Island coverage parameters for physician services across benefit packages (RIte Care, CSHCN, Substitute Care, RHP, RHO Phase One, ACA Adult Expansion), including covered services, limitations, exclusions, authorization requirements, and billing guidance (consultation coding).

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyPhysician Services (Covered Benefit)

Policy CodePolicy N/A

Change TypeRevised

Effective DateApr 23, 2010

Next Review Date

Key ActionObtain authorization for any out-of-network consultation; specialty visits to non-NHP providers must show required expertise not available in-network.

POLICY UPDATE CHANGES

Effective January 1, 2014, Neighborhood will no longer reimburse for consultation level coding; consultations should be reported under E/M code sets.

PEC date updated to 12/22/14 in version history.

1Adult Routine Office Visits allowed per rolling year

MultipleCovered Service Types (listed)

EFP restrictedEFP members - benefit restriction

Coverage Summary

Subject: Physician Services (Covered Benefit). Scope: Defines Neighborhood Health Plan of Rhode Island coverage parameters for physician services across benefit packages (RIte Care, Children with Special Health Care Needs, Substitute Care, Rhody Health Partners, Rhody Health Options Phase One, and ACA Adult Expansion), including covered services, limitations, exclusions, authorization requirements, and billing guidance (consultation coding).

Key stats & thresholds

Adult Routine Office Visits allowed per rolling year1 unit

Covered Service Types (examples)Physician office, inpatient, ER, home visits, observation, critical care, newborn, OMT, glucose monitoring

Behavioral health limited billing (legacy)CPT 90862 (deleted 1/1/13) may be billed with an E/M for limited pharmacologic management

Consultation coding policyConsultation CPT codes not reimbursed effective 2014-01-01; report under new/established E/M code sets

EFP membersRestricted physician benefit package — see EFP Benefit Coverage Summary

Coding Guidance and Code Groups

Consultation codingCPTNot Covered

consultation codes

Consultation level coding — not reimbursed effective January 1, 2014; should be reported under new and established E/M code sets.

Behavioral health limited billing (legacy)CPT

90862

Pharmacologic management (deleted code effective 1/1/13); primary care practitioners may bill for limited behavioral health management when billed with an Evaluation and Management code (legacy code usage).

Operational note: Effective January 1, 2014 consultations are not reimbursed; consultation codes should be reported under the new and established Evaluation and Management (E/M) code sets. Legacy billing note: primary care practitioners may bill for limited behavioral health pharmacologic management using CPT code 90862 (deleted effective 1/1/13) when billed with an Evaluation and Management code.

Actions for Providers

Prior Authorization

Out-of-network consultation authorization required

Obtain authorization for any out-of-network consultation; specialty visits to non-NHP providers must show required expertise not available in-network.

Billing Rule

Consultation codes not reimbursed

Do not bill consultation level CPT codes; report those services under new/established Evaluation and Management code sets effective 2014-01-01.

Billing Rule

Adult routine visit frequency limit

Limit billing for Adult Routine Office Visits (PCP) to 1 unit per rolling year.

Documentation Required

EFP members - restricted benefit documentation

For Extended Family Planning members, verify plan-specific covered physician services using the EFP Benefit Coverage Summary and document member's benefit status.

Background

Background: Physician services include routine physicals, sick visits, specialty office visits, consultations, observation, inpatient care, and home visits. Some services may also be rendered by licensed and credentialed nurse practitioners and physician assistants. The PCP role is supported by the Plan, and certain services are only covered when rendered by the member's PCP or covering practitioner. Authorization is required for out-of-network consultations and specialty visits to non-NHP providers are covered only when needed expertise is not available in-network.

Definition — Primary Care Practitioner (PCP): A practitioner in Pediatrics, Obstetrics/Gynecology, Family Practice, or Internal Medicine (inclusive of nurse practitioners) who is credentialed by the Plan and contracted as a PCP.

Revision History

2014-01-01policy_change

Effective January 1, 2014, Neighborhood will no longer reimburse for consultation level coding; consultation codes should be reported under the new and established Evaluation and Management (E/M) code sets. This aligns with CMS discontinuation of consultation reimbursement (CMS discontinued reimbursement effective January 1, 2010).

2014-12-22administrative_updateLatest

Administrative update to version history: PEC date updated to 12/22/14.