CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Assisted Living Eff 3.1.2018 Through 3.15.2022

Defines Neighborhood Health Plan of Rhode Island coverage, medical necessity criteria, billing, prior authorization, and documentation requirements for Assisted Living services (base, enhanced, skilled enhanced, and dementia care) for UNITY and INTEGRITY lines of business within state licensure scope.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyAssisted Living Eff 3.1.2018 Through 3.15.2022

Policy CodePolicy N/A

Change TypePolicy creation

Effective DateMar 1, 2018

Next Review Date

Key ActionPrior authorization is required for all Assisted Living services; providers must refer to Neighborhood's Medical Management Request Forms and contact Utilization Management for questions.

SourceLink

POLICY UPDATE CHANGES

Policy created and effective 3/1/2018.

4Covered levels of care

3ADL minimums (base/enhanced/dementia)

Per diemPayment methodology

Coverage Summary

This policy covers Neighborhood Health Plan of Rhode Island’s Assisted Living services for the UNITY and INTEGRITY lines of business. Assisted Living services provide supervision, security, and personalized assistance with activities of daily living to maximize member independence in residential community care facilities. Covered levels include Base Level, Enhanced (non‑skilled), Enhanced (skilled), and Dementia Care assisted living. The policy and all services must be provided within the scope of state licensure pursuant to R.I.G.L. §23-17.4. It defines medical necessity, billing and reimbursement (per diem), prior authorization, and documentation requirements for these levels of care for UNITY and INTEGRITY members.

Medical Necessity and Levels of Care

General Medical Necessity

All services must be medically necessary to qualify for reimbursement. Members must meet level of care requirements as outlined below:

Medically necessary: Service is medically necessary
Licensure scope: Service is provided within scope of licensure pursuant to R.I.G.L. §23-17.4
Prior authorization obtained
Prior authorization is required for all Assisted Living services; see Utilization Management

Base Level Assisted Living - Criteria

Medication administration/oversight: Must require medication administration and/or oversight
ADL minimum: Must require assistance with a minimum of two (2) activities of daily living>= 2 ADLs
Activities of Daily Living (ADLs) defined in policy
Personal care hours: Must require six (6) or more hours of personal care per week>= 6 hours per week

Enhanced Level Assisted Living - Criteria

ADL minimum: Must require assistance with a minimum of two (2) activities of daily living>= 2 ADLs
Activities of Daily Living (ADLs) defined in policy
Combined service hours: Must require between seven (7) and twelve (12) hours per week of any combination of personal care, limited health care services, care coordination (including behavioral health), and/or health and home stabilization services7-12 hours per week

Dementia Care Assisted Living - Criteria

Dementia diagnosis: Member must have a diagnosis of Alzheimer's disease or another related dementia, and be determined to need memory care
ADL minimum: Must need assistance with a minimum of three (3) activities of daily living>= 3 ADLs
Activities of Daily Living (ADLs) defined in policy
Combined service hours: Must require thirteen (13) hours or more per week of any combination of personal care, limited skilled nursing, and/or behavioral health or health and home stabilization services>= 13 hours per week

Provider Actions & Requirements

Prior Authorization

Prior authorization required

Prior authorization is required for all Assisted Living services. Providers must refer to Neighborhood's Medical Management Request Forms for details and contact Utilization Management for questions.

Billing Rule

Per diem reimbursement and billing forms

Assisted Living is reimbursed on a per diem basis (rates inclusive of contracted services). Approved HCPCS code T2031 with modifiers for base, enhanced, skilled enhanced, and dementia care must be used. Providers credentialed for base and enhanced services bill on UB-04 (CMS-1450) or electronic 837I; providers credentialed for base, enhanced, and dementia bill on CMS-1500 or electronic 837P. Claims may be billed with a date span only if services were provided consecutively on each date within the span and dates are within the same month. Any break in service within a date span must be indicated on a new claim line.

Affected code: T2031 (per diem assisted living) with modifiers U1, U3, U4 as applicable
Billing forms: UB-04 (CMS-1450) or 837I for base/enhanced; CMS-1500 or 837P when dementia services included
Date-span billing allowed only for consecutive dates within same month; breaks require a new claim line

Documentation Required

Treatment record and ISP requirements

Providers must maintain a treatment record for each member that includes member identification, physician's order supporting need for skilled services, member diagnosis, initial admission assessment, and an Individual Service Plan (ISP). The ISP must be written by a registered nurse or certified assisted living administrator within seven (7) days after move-in and must document services and interventions needed, frequency and duration, party responsible for providing services, and date and signature of the RN and/or certified assisted living administrator.

Member identification (Neighborhood ID, name)
Physician's order for skilled services
Member diagnosis
Initial admission assessment
ISP written within 7 days by RN or certified assisted living administrator, including services, frequency/duration, responsible party, and RN/administrator signature

Billing Rule

Timely filing and claim adjustments

Billable services must meet contractual timely filing requirements. Adjustments, corrections, and reconsiderations require the required forms and must comply with national claims standards and formats for submission.

Submit within contractual timely filing timeframes
Adjustments/corrections/reconsiderations must include required forms
All submissions must comply with national claims standards (e.g., X12/NUCC/NUBC)

Denial Risk

Audit and medical necessity enforcement

Claims are subject to audit and may be denied if services fail to meet medical necessity, lack required documentation, do not have prior authorization, are improperly coded, are outside provider contract terms, or do not satisfy state or federal requirements.

Denials may result from lack of medical necessity
Insufficient or missing documentation in the treatment record or ISP
Missing prior authorization
Incorrect coding or modifier use
Noncompliance with contract or state/federal regulations

Definitions & Background

Assisted Living services are intended to maximize continued independence for members living in residential community care facilities by providing supervision, safety, and assistance with activities of daily living. This policy applies to Neighborhood’s UNITY and INTEGRITY lines of business and requires services to be provided within the applicable state licensure scope; prior authorization is required for all Assisted Living services. Policy creation/effective date: 3/1/2018.

Definitions - Activities of Daily Living (ADLs)

ADLs - BathingDirect care or constant supervision and cueing during the entire activity of a shower, bath, or sponge bath to maintain adequate hygiene.

ADLs - DressingDirect care or constant supervision and cueing during the entire activity of dressing and undressing, including assistance with prostheses, braces, anti‑embolism garments, or assistive devices.

ADLs - EatingDirect care, supervision/cueing, or physical assistance for portion or all of meals to consume food or drink via mouth using routine or adapted utensils, including ability to cut, chew, and swallow.

ADLs - Personal Hygiene/GroomingDirect care or constant supervision and cueing during combing hair, brushing teeth, shaving, make‑up application, nail care, eyeglasses, and jewelry application.

ADLs - MobilityAssistance when member must be steadied, assisted, or guided in ambulation, or is unable to self‑propel a wheelchair.

ADLs - TransferringAssisting or lifting the member between surfaces (e.g., bed to chair or wheelchair), repositioning for pressure relief, or transfer to bed during the day.

OpenPayer

Assisted Living Eff 3.1.2018 Through 3.15.2022

Coverage Summary

Medical Necessity and Levels of Care

Coding

Provider Actions & Requirements

Definitions & Background

Revision History

T2031	Assisted Living, waiver; per diem, base level
T2031	Assisted Living, waiver; per diem, enhanced non-skilled
T2031	Assisted Living, waiver; per diem, enhanced skilled
T2031	Assisted Living, waiver; per diem, dementia care