CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Physician Services Benefit Coverage Summary Archive

Defines covered physician services, limitations, exclusions, and billing guidance for Neighborhood Health Plan of Rhode Island benefit packages (RIte Care, CSHCN, Substitute Care, RHP, RHO Phase One, ACA Adult Expansion). Applies to physician services rendered by credentialed providers, including some services by nurse practitioners and physician assistants.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyPhysician Services Benefit Coverage Summary Archive

Policy CodePolicy N/A

Change TypeRevised; Clarified

Effective DateJan 1, 2014 (coding change)

Next Review Date

Key ActionObtain authorization for out-of-network consultations before rendering services.

SourceLink

POLICY UPDATE CHANGES

Effective January 1, 2014, Neighborhood will no longer reimburse for consultation level coding.

Behavioral health billing guidance updated to reference deletion of CPT 90862 effective 1/1/13 and use of T1015 for treatment beyond medication management.

1Adult Routine Office Visits per Rolling Year

6Benefit Packages Listed

2Notable Coding Notes

Coverage Summary

Physician services include routine and specialty outpatient care, inpatient and observation services, home visits, newborn services, limited behavioral health management, and other physician-rendered services; some services may also be rendered by licensed and credentialed nurse practitioners and physician assistants. Covered benefit packages include RIte Care, Children with Special Health Care Needs (CSHCN), Substitute Care, Rhody Health Partners (RHP), Rhody Health Options Phase One, and ACA Adult Expansion (RHE). Primary Care Practitioners (PCPs) play a central role in care delivery, and certain services are only covered when rendered by the member's PCP or the PCP's covering practitioner. Specialty visits to non‑Neighborhood providers require that the particular expertise is not available within the Neighborhood network, and authorization is required for out‑of‑network consultations. Adult routine office visits are limited to 1 unit per rolling year.

Key Thresholds & Summary

Adult Routine Office Visit Frequency1 unit per rolling year

Benefit Packages ListedRIte Care; Children with Special Health Care Needs; Substitute Care; Rhody Health Partners (RHP); Rhody Health Options Phase One; ACA Adult Expansion (RHE)

Notable Coding NotesConsultation level coding not reimbursed effective Jan 1, 2014; limited behavioral health billing historically referenced CPT 90862 (deleted 1/1/13) and T1015 for treatment beyond medication management.