ModifiedNeighborhood Health Plan of Rhode IslandPolicy N/A

Speech Therapy Services Payment Policy – Archive 3

Defines coverage, limits, exclusions, coding, documentation, and claim submission rules for speech-language pathology services across Medicaid (excluding EFP), INTEGRITY, and Commercial lines for Neighborhood Health Plan of Rhode Island.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicySpeech Therapy Services Payment Policy – Archive 3

Policy CodePolicy N/A

Change TypeRevised coverage limits and prior authorization rules

Effective DateOct 1, 2020

Next Review Date

Key ActionObtain prior authorization for additional speech therapy sessions when member has exceeded 24 sessions in a calendar year for INTEGRITY line of business.

SourceLink

POLICY UPDATE CHANGES

04/01/21 - Policy Update: Remove benefit limit of 24 visits for Medicaid and Commercial LOBs effective 4/1/21.

01/01/21 - Policy Updates: Benefit limit/prior authorization requirements for Commercial and INTEGRITY; Medicaid limit updated to calendar year instead of rolling year.

11/05/20 - Policy Review/Approval Date for 1/1/21 changes.

10/01/20 - Policy Effective Date.

09/14/20 - Policy Review/Approval Date.

24INTEGRITY sessions without prior auth

MultipleCovered CPT/HCPCS codes listed

ManyListed coverage exclusions

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Policy Summary

Background: Speech-language therapy services assist with the development of human communication and evaluate and/or treat speech, language, cognitive-linguistic, feeding, or swallowing impairments related to a specific illness, injury, or congenital or neurodevelopmental condition; services must be evidence-based and demonstrate measurable improvement potential.

Scope Summary: This policy defines coverage, limits, exclusions, coding, documentation, and claim submission rules for speech-language pathology services across Medicaid (excluding Extended Family Planning), INTEGRITY, and Commercial lines of business — including covered CPT/HCPCS codes, documentation and medical necessity requirements, claim submission standards, and specific limits such as an INTEGRITY allowance of 24 sessions per calendar year without prior authorization (additional sessions require prior authorization); note that the prior 24-visit benefit limit was removed for Medicaid and Commercial effective 04/01/21.

Policy Metadata

Effective Date2020-10-01

Last Review2021-04-01

Next Review

Policy NumberN/A

SubjectSpeech Therapy Services Payment Policy

Coverage Stancemixed

Has Material Changetrue - removed 24-visit limit for Medicaid & Commercial effective 04/01/21; INTEGRITY retains 24-session rule

Medical Necessity & Coverage Criteria

Early Intervention Referral

Early Intervention Referral: Children up to age three (3) years with developmental delays and related conditions should be referred to Early Intervention for evaluation and treatment prior to requesting services from Neighborhood

Codes & Billing Categories

Covered CPT/HCPCS Codes (examples listed in policy)CPT|HCPCSCovered

92507	Treatment of speech, language, voice, communication, and/or auditory processing disorder; individual
92508	Treatment of speech, language, voice, communication, and/or auditory processing disorder; group, 2 or more individuals
92521	Evaluation of speech fluency (eg, stuttering, cluttering)
92522	Evaluation of speech sound production (eg, articulation, phonological process, apraxia, dysarthria)
92523	Evaluation of speech sound production with evaluation of language comprehension and expression (eg, receptive and expressive language)
92524	Behavioral and qualitative analysis of voice and resonance
92526	Treatment of swallowing dysfunction and/or oral function for feeding
92607	Evaluation for prescription for speech-generating augmentative and alternative communication device, face-to-face with the patient; first hour
92608	Evaluation for prescription for speech-generating augmentative and alternative communication device; each additional 30 minutes (List separately in addition to code for primary procedure)
92610	Evaluation of oral and pharyngeal swallowing function

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Authorization, Documentation & Billing Rules

Prior Authorization

Prior Authorization Required

For INTEGRITY members who have exceeded the no-authorize allowance, providers must obtain prior authorization before delivering additional speech therapy sessions beyond the plan's allowance. Prior authorization is required once the member has exceeded 24 sessions in a calendar year for INTEGRITY line of business.

INTEGRITY allowance: 24 sessions per calendar year — prior authorization required for additional sessions
Refer to Neighborhood's Prior Authorization Reference page for submission instructions and required clinical information

Documentation Required

Medical Record Documentation

Maintain complete medical record documentation that supports the services billed and demonstrates medical necessity. Records should include treatment plans, measurable goals, progress notes, evaluations, modality used, time spent, and any supporting diagnostic information. Neighborhood reserves the right to request medical records and follows CMS standards for proper documentation.

Policy Changes & Timeline

09/14/20added

Policy Review/Approval Date.

10/01/20added

Policy Effective Date.

11/05/20revised

Policy Review/Approval Date for 1/1/21 changes.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicySpeech Therapy Services Payment Policy – Archive 3

Policy CodePolicy N/A

Change TypeRevised coverage limits and prior authorization rules

Effective DateOct 1, 2020

Next Review Date

Key ActionObtain prior authorization for additional speech therapy sessions when member has exceeded 24 sessions in a calendar year for INTEGRITY line of business.

SourceLink

On This Page

Documentation must support billed CPT/HCPCS codes and billable units

Progress notes must show measurable improvement or continued medical necessity

Neighborhood may request records for review or audit; retain records per contractual/state requirements

Billing Rule

Timely Filing and Claim Submission

Submit complete and accurate claims within Neighborhood's and contractual timely filing guidelines. Use correct and current coding and adhere to National Claims Standards.

Follow CPT, ICD-10-CM, and HCPCS coding standards (AMA CPT code set, ICD-10-CM, HCPCS Level II)
Include required forms for adjustments, corrections, and reconsiderations
Ensure claims reflect the service, provider, date of service, units and supporting documentation

Denial Risk

Denial Risk for Excluded Services

Services excluded from coverage or at high risk for denial include non-covered settings, non-skilled or maintenance services, duplicative services, and device-associated services. Review these common denial reasons before submitting claims.

Group therapy (e.g., CPT 92508) when policy excludes group settings
Maintenance programs and services when therapeutic goals have been met or no progress is expected
Non-skilled services that do not require a qualified provider
Services provided solely for convenience of the member or provider
Services duplicative of other Medicaid-funded benefits
Services and items associated with Altered Auditory Feedback (AAF) devices, including the devices

INTEGRITY no-PA sessions threshold24 sessions per calendar year

Other numeric thresholdsNone specified

01/01/21revised

Policy Updates: Benefit limit/prior authorization requirements for Commercial and INTEGRITY; Medicaid limit updated to calendar year instead of rolling year.

04/01/21revisedLatest

Policy Update: Remove benefit limit of 24 visits for Medicaid and Commercial LOBs effective 4/1/21. (INTEGRITY retains 24-session allowance without prior authorization.)