CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Adult Day Health Payment Policy – Archive 5

Defines payment, billing, coverage prerequisites, levels of care, exclusions, and coding for Adult Day Health services for Neighborhood Health Plan of Rhode Island Medicaid products (excludes certain Medicaid subprograms and commercial plans).

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyAdult Day Health Payment Policy – Archive 5

Policy CodePolicy N/A

Change TypeRevised (billing/modifier guidance)

Effective DateSep 1, 2013

Next Review Date

Key ActionFor Enhanced Level billing, document required services in the care plan signed by the participant or legal guardian/representative and complete required progress notes.

SourceLink

POLICY UPDATE CHANGES

Added language that all other modifiers outside of U1/U3 will not process correctly.

Removed additional criteria from policy for Enhanced Level Skilled.

No content changes noted on 09/29/2021 (annual review).

3Defined Levels of Care

2HCPCS Codes Covered

2Required Modifiers

7Explicit Exclusions Listed

This policy covers Adult Day Health programs: comprehensive, nonresidential day programs that provide supervision, nursing, therapies, personal care assistance, social and recreational activities, meals and other services for adults who return home at the end of the day (per Rhode Island EOHHS managed care contract definition).

Payer/scope: applies to Neighborhood Health Plan of Rhode Island Medicaid products. Commercial plans are excluded. Medicaid product coverage specifically excludes Extended Family Planning (EFP), Children with Special Health Care Needs (CSN) < 18 years of age, and Substitute Care (SUB) < 18 years of age.

Covered codes and billing overview: HCPCS S5101 (day care services, adult; per half day) and S5102 (day care services, adult; per diem) may be covered when criteria are met. Basic Level is billed with no modifier; Enhanced Level Non Skilled requires modifier U1; Enhanced Level Skilled requires modifiers U1 and U3. Document history notes that all other modifiers outside of U1/U3 will not process correctly (added 11/28/2023).

This document defines payment, billing, coverage prerequisites, levels of care, exclusions, and coding for Adult Day Health services and includes requirements for medical necessity, face-to-face PCP assessment, level-specific criteria, exclusions, and claim submission/billing guidance.

Policy metadata and thresholds

Effective Date2013-09-01

Last Review2023-11-28

Next Review

StatusCURRENT

Defined Levels of Care3

HCPCS Codes CoveredS5101, S5102

Required ModifiersU1, U3

Explicit Exclusions Listed7

Minimum daily attendance>= 4 hours per day

Maximum days per weekup to 6 days per week

Total transportation time<= 2 hours round trip

Medical necessity & eligibility criteria

General Medical Necessity and Eligibility

Services reimbursable when ALL of the following are met:

ALL of the following

Service is medically necessary and may be evaluated against NCD, LCD, InterQual, RI EOHHS recommendations, or Neighborhood Clinical Medical Policies
Member is eligible under Neighborhood Medicaid product (excludes EFP, CSN <18, SUB <18)
Service is not duplicative of other Medicaid-funded services the individual has chosen
Member is not a resident of a residential health care facility
Member is not receiving 24-hour inpatient hospital or nursing home care
Member is not receiving partial care/partial hospitalization services on the same day
Member is not enrolled in the Personal Choice Program
Provider verifies eligibility, coverage and authorization prior to rendering services

Face-to-face Assessment Requirement

Face-to-face assessment and reassessment with the member's Primary Care Provider (PCP) is required annually or if the member's condition changes

Levels of Care and Level-Specific Criteria

Member must meet criteria for one of the following levels:

ONE of

Basic Level
- Minimum of four (4) hours per day up to six (6) days per week>= 4 hours per day; up to 6 days per week
- Transportation included in per diem; total transportation not to exceed two (2) hours to and from home<= 2 hours round trip
- Physical, occupational, and speech therapy are not included in the per diem rate and must be billed separately
  Therapies billed separately from per diem
Enhanced Level Non Skilled

Codes, modifiers, and billing guidance

Covered HCPCS (Adult Day Health services)HCPCSCovered

S5101	Day care services, adult; per half day.
S5102	Day care services, adult; per diem

Required Modifiers for Enhanced LevelsModifier

U1	Medicaid level of care 1, as defined by each state (Adult Day Enhanced Level Non Skilled)
U3	Medicaid level of care 3, as defined by each state (Enhanced Level Skilled when applicable)

Billing Modifiers Guidance / Not ProcessedModifier

other

All other modifiers outside of U1/U3 will not process correctly (document history note: added 11/28/2023)

What providers must do / billing rules

Billing Rule

Modifier use by level

Basic Level: bill with no modifier. Enhanced Level Non Skilled: bill with modifier U1. Enhanced Level Skilled: bill with modifiers U1 and U3. Affected codes: S5101, S5102, U1, U3.

Basic Level — no modifier
Enhanced Level Non Skilled — modifier U1
Enhanced Level Skilled — modifiers U1 and U3
Affected codes: S5101, S5102, U1, U3

Billing Rule

Modifier processing limitation

All modifiers other than U1 and U3 will not process correctly. This change was added in the 11/28/2023 document history.

Only U1 and U3 are supported for Enhanced Level processing
Other modifiers outside U1/U3 may not process correctly (effective 11/28/2023)

Documentation Required

Care plan and progress notes for Enhanced Levels

For Enhanced Level billing, document the required services in the care plan signed by the participant or legal guardian/representative and complete the required progress notes. Affected billing codes: S5101 and S5102.

Care plan must be signed by participant or legal guardian/representative
Complete required progress notes
Affected codes: S5101, S5102

Documentation Required

Face-to-face PCP assessment

Obtain a face-to-face assessment and reassessment with the member's Primary Care Provider (PCP) annually or whenever the member's condition changes.

Annual PCP face-to-face assessment required
Reassess if the member's condition changes

Prior Authorization

Authorization and eligibility verification

Verify member eligibility, coverage and authorization prior to rendering services. Refer to Neighborhood's Prior Authorization Reference page and Neighborhood Clinical Medical Policies for details.

Verify eligibility, coverage, and authorization before providing services
See Neighborhood's Prior Authorization Reference page
See Neighborhood Clinical Medical Policies

Billing Rule

Timely filing and claim completeness

Submit complete claims within contractually determined timely filing guidelines. Billable services are subject to contractual agreements and must meet coding and documentation standards.

Submit complete claims within timely filing guidelines per contract
Billable services subject to contractual agreements and coding/documentation standards

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyAdult Day Health Payment Policy – Archive 5

Policy CodePolicy N/A

Change TypeRevised (billing/modifier guidance)

Effective DateSep 1, 2013

Next Review Date

Key ActionFor Enhanced Level billing, document required services in the care plan signed by the participant or legal guardian/representative and complete required progress notes.

SourceLink

On This Page

OpenPayer

Adult Day Health Payment Policy – Archive 5

Policy summary

Medical necessity & eligibility criteria

Codes, modifiers, and billing guidance

What providers must do / billing rules

Key terms

Document changes