CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

In Lieu of Services for chronic pain (chiropractic, acupuncture, massage)

Defines Neighborhood Health Plan of RI coverage and limits for in-lieu-of services (chiropractic, acupuncture, massage) as alternatives to medications or invasive procedures for members in Medicaid and INTEGRITY lines of business.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyIn Lieu of Services for chronic pain (chiropractic, acupuncture, massage)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 1, 2018

Next Review DateN/A

Key ActionComplete the Neighborhood In Lieu Of Prior Authorization Request Form and attest the service is being used 'in lieu of' the described State Plan service.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

12chiropractic visits per rolling year

12acupuncture visits per rolling year

6massage therapy visits per rolling year

90claim submission timeframe

Coverage Criteria

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.

Coverage criteria for In Lieu of Services

Covered when ALL of the following are met

Covered services: Service is one of the approved in-lieu services: chiropractic, acupuncture, or massage used as a substitute for medications or invasive procedures for chronic pain.

See Covered Services list

Medical necessity: Service is determined to be medically necessary and effective in treating the member's pain and improving quality of health per NCD/LCD, Interqual, EOHHS recommendations, or Clinical Medical Policies.

Provider must attest via In Lieu Of Prior Authorization Request Form

Prior authorization/attestation: Provider completes Neighborhood In Lieu Of Prior Authorization Request Form attesting the service is being used 'in lieu of' the described State Plan Service.

Providers responsible for verifying eligibility and coverage prior to rendering services.

Benefit limits: Service does not exceed the specified visit limits per rolling year (see Benefit Limitations).

Chiropractic 12/yr; Acupuncture 12/yr; Massage 6/yr

Services that are not medically necessary are not eligible for reimbursement. Neighborhood determines medical necessity using sources such as National Coverage Determinations (NCD), Local Coverage Determinations (LCD), industry‑accepted criteria like InterQual, EOHHS recommendations, and Neighborhood Clinical Medical Policies. Providers must verify eligibility, coverage, and authorization prior to rendering services and complete the required attestation on the Neighborhood In Lieu Of Prior Authorization Request Form.

Conservative Treatment Requirements

Attestation on In Lieu Of Prior Authorization Request Form and demonstration of medical necessity per payer criteria.

Provider attestation and demonstration of medical necessity are required as described below.

Form completion: Requesting provider must complete the Neighborhood In Lieu Of Prior Authorization Request Form.

Form must include provider attestation that the service is being used 'in lieu of' the described State Plan Service.

Attestation content: Provider attests on the form that the requested service is being used as a substitute for a State Plan service (i.e., in lieu of medications or invasive procedures).

Attestation is required for prior authorization review.

Medical necessity documentation: Provider demonstrates that the service is medically necessary and effective for treating the member's pain and improving quality of health using accepted criteria (NCD/LCD, Interqual, EOHHS recommendations, or Clinical Medical Policies).

Neighborhood may use these criteria to determine medical necessity.

Provider responsibilities: Provider is responsible for verifying member eligibility, coverage, and authorization prior to rendering services.

See Neighborhood guidance materials and Prior Authorization Reference page for details.

Provider Actions & Requirements

Prior Authorization

Prior Authorization Required

Prior Authorization and Medical Necessity: Prior authorization is required for In Lieu Of services. Requests must be submitted via Neighborhood's In Lieu Of Prior Authorization Request Form and include documentation demonstrating medical necessity. Neighborhood may use National Coverage Determinations (NCD), Local Coverage Determinations (LCD), industry-accepted criteria (for example, InterQual), EOHHS recommendations, and Neighborhood Clinical Medical Policies (CMP) to determine medical necessity. Providers are responsible for verifying member eligibility, coverage, and any authorization criteria before rendering services.

Submit requests using the Neighborhood In Lieu Of Prior Authorization Request Form
Authorization will be reviewed against NCDs, LCDs, InterQual, EOHHS guidance, and Neighborhood CMPs
Contact Provider Services at 1-800-963-1001 for assistance

Note

Allowed Only as Substitutes for State Plan Services

Use as Substitute for State Plan Services: In Lieu Of services are alternatives that Neighborhood may provide as substitutes for specified State Plan services when approved by EOHHS and when the requesting provider attests that the service is being used 'in lieu of' the described State Plan service. These services must be effective in treating the member's condition and improve the member's health or quality of life to qualify for reimbursement.

EOHHS-approved services only
Provider must attest that the service is being used 'in lieu of' the State Plan service

Documentation Required

Provider Attestation Required

Attestation and Verification: The requesting provider must complete and sign the Neighborhood In Lieu Of Prior Authorization Request Form attesting that the requested service is being provided "in lieu of" the specified State Plan service and that it is medically necessary and effective for the member. Failure to provide the required attestation or supporting documentation may result in denial of the request. It is the provider's responsibility to verify eligibility, coverage, and authorization prior to providing services.

Provider attestation required on Neighborhood In Lieu Of Prior Authorization Request Form
Insufficient attestation or documentation may lead to denial
Providers must verify member eligibility and coverage before delivering services

Procedure Codes

Covered procedure CPT/HCPCS codesCPTCovered

97110	Therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility.
97112	Therapeutic procedure, 1 or more areas, each 15 minutes; neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities.
97124	Therapeutic procedure, 1 or more areas, each 15 minutes; massage, including effleurage, petrissage and/or tapotement (stroking, compression, percussion).
97140	Manual therapy techniques (eg, mobilization/ manipulation, manual lymphatic drainage, manual traction), 1 or more regions, each 15 minutes.
97810	Acupuncture, 1 or more needles; without electrical stimulation, initial 15 minutes of personal one-on-one contact with the patient.
97811	Acupuncture, 1 or more needles; without electrical stimulation, each additional 15 minutes of personal one-on-one contact with the patient, with re-insertion of needle(s) (List separately in addition to code for primary procedure).
97813	Acupuncture, 1 or more needles; with electrical stimulation, initial 15 minutes of personal one-on-one contact with the patient.
97814	Acupuncture, 1 or more needles; with electrical stimulation, each additional 15 minutes of personal one-on-one contact with the patient, with re-insertion of needle(s) (List separately in addition to code for primary procedure).
98940	Chiropractic manipulative treatment (CMT); spinal, 1-2 regions.
98941	Chiropractic manipulative treatment (CMT); spinal, 3-4 regions.

1–10 of 11

1/2

Frequency Limits

inv-12: Chiropractic services — 12 visits

Limit12 visits per rolling year

ScopeChiropractic services used as in‑lieu alternative to medications or invasive procedures for chronic pain

AuthorizationSubject to provider attestation on Neighborhood In Lieu Of Prior Authorization Request Form and medical necessity criteria

inv-13: Acupuncture services — 12 visits

Limit12 visits per rolling year

ScopeAcupuncture services used as in‑lieu alternative to medications or invasive procedures for chronic pain

AuthorizationSubject to provider attestation on Neighborhood In Lieu Of Prior Authorization Request Form and medical necessity criteria

inv-14: Massage therapy services — 6 visits

Limit6 visits per rolling year

ScopeMassage therapy services used as in‑lieu alternative to medications or invasive procedures for chronic pain

AuthorizationSubject to provider attestation on Neighborhood In Lieu Of Prior Authorization Request Form and medical necessity criteria

Definitions

inv-10: In Lieu of Services — Alternative services which Neighborhood may provide as medically appropriate therapy to be used as substitutes for other state plan services

DefinitionAlternative services which Neighborhood may provide as medically appropriate therapy to be used as substitutes for other state plan services, approved by Rhode Island EOHHS.

UseIntended as substitutes for medications or invasive procedures for chronic pain when determined effective

ApprovalServices must be approved by Rhode Island Executive Office of Health and Human Services (EOHHS) to be considered In Lieu of Services

Authorization requirementProvider must attest on the Neighborhood In Lieu Of Prior Authorization Request Form that the service is being used 'in lieu of' a State Plan service

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyIn Lieu of Services for chronic pain (chiropractic, acupuncture, massage)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 1, 2018

Next Review DateN/A

Key ActionComplete the Neighborhood In Lieu Of Prior Authorization Request Form and attest the service is being used 'in lieu of' the described State Plan service.

SourceLink

On This Page

OpenPayer

In Lieu of Services for chronic pain (chiropractic, acupuncture, massage)

Coverage Criteria

Conservative Treatment Requirements

Provider Actions & Requirements

Procedure Codes

Frequency Limits

Imaging Requirements

Definitions

Background