CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Assisted Living services — Coverage, reimbursement, and documentation

Governs Neighborhood Health Plan of Rhode Island coverage, reimbursement, and documentation requirements for assisted living services for Medicaid (excluding EFP), Integrity, and Commercial lines; applies to participating and non-participating providers.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyAssisted Living services — Coverage, reimbursement, and documentation

Policy CodePolicy N/A

Change TypeTier language & coding updates

Effective DateN/A

Next Review DateN/A

Key ActionVerify eligibility, coverage and prior authorization criteria and use appropriate T2031 code variants before rendering services.

SourceLink

POLICY UPDATE CHANGES

Updated coverage exclusions to include correct level of care tier.

Updated Tier language and coding for RI Assisted Living Rate Reform (Tier A, B, C) and coding effective dates.

3 tiersDefined assisted living tiers (A, B, C)

Per diemReimbursement basis

T2031 variantsBilling codes listed

≤7 daysISP timing

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Coverage criteria and eligibility

Tier eligibility criteria

Covered when the member meets the tier-specific ADL and service time requirements and services are medically necessary:

Tier A: Daily assistance with at least two (2) ADLs AND at least one (1) hour of personal care2 ADLs + >=1 hour/day personal care

Tier A definition

Tier B: Extensive assistance with a minimum of two (2) ADLs OR seven (7) or more hours per week of any combination of personal care, limited health care services, and care coordination (including behavioral health/memory care or complex medication management)2 ADLs OR >=7 hours/week

Tier B definition

Tier C: Extensive assistance with a minimum of three (3) ADLs AND personal care AND sixteen (16) hours or more per week of any combination of limited health care services and care coordination (including behavioral health/memory care or complex medication management)3 ADLs + >=16 hours/week

Tier C definition

The Assisted Living benefit specifically excludes coverage for facility room and board. Services that are excluded also include assisted services for members enrolled in an Adult Day program and other services that are similar or duplicative in nature.

Neighborhood reserves the right to deny claims when the submitted level of care tier is incorrect or does not match the member’s approved tier from RI EOHHS. Claims submitted with an incorrect tier or that mismatch the member’s approved RI EOHHS tier may be denied as not payable under the assisted living benefit.

Billing codes and tier service thresholds

Covered HCPCS CodesHCPCSCovered

T2031	Assisted living; Tier A Facility; Beneficiary A or B Member.
T2031-UB	Assisted living; Tier B Facility; Tier B Member.
T2031-UC	Assisted living; Tier C Facility; Tier C Member living;

Tier service hour thresholds

Tier ADaily assistance with at least two (2) ADLs AND at least one (1) hour of personal care (>=1 hour/day)

Tier BExtensive assistance with a minimum of two (2) ADLs OR seven (7) or more hours per week of any combination of personal care, limited health care services, and care coordination (including behavioral health/memory care or complex medication management)

Tier CExtensive assistance with a minimum of three (3) ADLs AND personal care AND sixteen (16) hours or more per week of any combination of limited health care services and care coordination (including behavioral health/memory care or complex medication management)

Provider responsibilities, prior auth, and documentation

Prior Authorization

Prior authorization and code verification — Providers must verify eligibility, coverage and authorization criteria prior to rendering services

Providers must verify member eligibility, coverage, and authorization criteria prior to rendering services. Confirm Prior Authorization (when required) and the approved level-of-care tier with Neighborhood to avoid claim denials or delays.

Verify authorization and coverage before services are rendered
Contact Provider Services at 1-800-963-1001 for questions
Use Neighborhood's Prior Authorization Reference page and Clinical Medical Policies for plan-specific rules

Note

Provider actions — general operational responsibilities

Providers are responsible for operational steps necessary to deliver billable Assisted Living services in accordance with this policy and applicable contracts. This includes verifying member eligibility, obtaining necessary authorizations, submitting complete claims within contractual timely-filing limits, and ensuring documentation and coding follow CPT, ICD-10-CM, and HCPCS guidance.

Admission criteria for assisted living

Assisted living facility — admission criteria

Admission to Assisted Living: Member requires supervised residential care with personalized assistance per Tier A/B/C definitions; provider must have a physician's order supporting need for skilled services and an Individual Service Plan (ISP) completed within seven days of move-inPhysician order + ISP within 7 days

Admission requires documentation and meeting tier ADL/hours criteria

Criteria for continued stay

Assisted living facility — continued stay criteria

Continued stay: Documentation of regular member assessment and ISP review at least every 12 months or sooner if condition changes; services remain medically necessary and match approved tierISP review <= 12 months

Supports continued reimbursement

Discharge criteria

Discharge from an assisted living facility must be supported by the medical record, including any applicable re‑admission assessment and updates to the Individual Service Plan (ISP) required by state regulations. Records should document the change in need or reason for transfer and reflect that the member no longer meets the criteria for the approved level of care.

Billing day span and date rules

Assisted living facility — claim span rules

Consecutive date span billingClaims may be billed with a consecutive date span when services were provided on each date within the span

Breaks in serviceAny break in service within a date span must be indicated on a new claim line

Same-month requirementDates of service included in a date span must be within the same month

Key definitions

Activities of Daily Living (ADLs) definitions

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

DressingDirect care or constant supervision and cueing during the entire activity of dressing and undressing, including putting on or removing prostheses, braces, anti-embolism garments, or assisted devices

EatingDirect care or constant supervision and cueing, or physical assistance for part or all of meals to consume food or drink by mouth using routine or adapted utensils, including ability to cut, chew, and swallow

ToiletingAssistance due to incontinence or scheduled/routine assistance, catheter or colostomy care, help transferring on/off the toilet, self‑cleansing, and changing briefs/pads

MobilityAssistance when the member must be steadied, assisted in ambulation, or is unable to self‑propel a wheelchair

Transferring

Background and scope

Assisted living services provide supervision and personalized assistance with activities of daily living and limited health‑related supports to maximize member independence in a residential community setting. Per policy, providers must maintain a treatment record that includes member identification, a physician’s order supporting the need for skilled services, diagnosis, an initial admission assessment, and an Individual Service Plan (ISP) written by a registered nurse or certified assisted living administrator within seven (7) days of move‑in. The ISP must describe the frequency and duration of services, identify responsible parties, include the nurse’s review and signature/date, and be reviewed at least annually or sooner if the member’s condition changes.

Policy revision history

2025-06-09Annual ReviewLatest

Updated coverage exclusions to include correct level of care tier.

2024-07-01Annual Review

Annual review; no content changes recorded.

2023-03-29Annual Review