CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Telemedicine/Telephone Services Payment Policy – Archive 3

Defines Neighborhood Health Plan of Rhode Island coverage, limitations, exclusions, billing, documentation and reimbursement rules for telemedicine/telehealth and telephone-only services across Medicaid, INTEGRITY, and Commercial lines of business, including temporary CMS-aligned expansions during COVID-19.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyTelemedicine/Telephone Services Payment Policy – Archive 3

Policy CodePolicy N/A

Change TypeRevisions and coding updates (2021–2023)

Effective Date

Next Review Date

Key ActionVerify patient eligibility and bill telemedicine claims with the specified POS/modifier rules and supporting documentation per CMS standards.

SourceLink

POLICY UPDATE CHANGES

04/18/2023 Policy Revision: Removed preventative medicine services section effective 5/12/23; updated T1016 from telemedicine only to telemedicine & audio effective 7/1/23; added CPTs T1017 and H2000 to coding grid.

01/27/2023 Policy Revision: Updated coding section to clarify requirements, added Doula service CPTs to Coding Grid and allowed Established E/M codes for Audio Only for PCPs effective 7/1/22.

05/01/2022 Policy Update & Review: Combined Telemedicine and Temporary Telemedicine Policies and updated language/coding to align with CMS, EOHHS, OHIC guidance.

01/20/2022 Policy update to include new POS 10 per CMS effective 4/1/22.

04/13/2021 Formatting Updates. No content changes.

>50CPT codes listed (temporary or permanent allowances)

2Coverage visit frequency limits (hospital, nursing facility)

Reimbursement rate (in-office allowable)

2023-12-31Temporary telemedicine allowance expiration

ManyTemporarily allowed through 12/31/2023

Coverage Summary

Scope: This policy defines Neighborhood Health Plan of Rhode Island coverage, limitations, exclusions, billing, documentation and reimbursement rules for telemedicine/telehealth and telephone-only services across Medicaid (excluding EFP), INTEGRITY, and Commercial lines of business. Subject: Telemedicine/Telephone Services Payment Policy (terms telemedicine and telehealth used interchangeably). Status: CURRENT. Effective/History notes: policy includes multiple revisions (see Document History), with material coding changes effective 7/1/23 and earlier pandemic-era expansions. Coverage summary: telemedicine/telehealth is defined as real-time, two-way synchronous audio, video, telephone-audio-only communications or electronic media to deliver clinical services and is covered when medical necessity and other policy criteria are met. Temporary pandemic-era expansions for additional codes are explicitly allowed through 12/31/2023 per the coding grid; providers must note these temporary allowances when billing.

Quick facts

Reimbursement rate100% of in-office allowable (1.00)

Temporary allowance expiration2023-12-31

Subsequent hospital visit limit1 telehealth visit every 3 days

Subsequent nursing facility visit limit1 telehealth visit every 14 days

Codes listed (part/approx)~120 (codes listed in sections) / ~160 (CPT codes listed in part 3)

Medical‑Necessity Criteria

General Coverage / Medical Necessity

Telemedicine/Telephone Services are covered when ALL of the following are met:

ALL of the following

The patient must be present at the time of service.
Services must be medically necessary and clinically appropriate to be provided through telemedicine.
The communication of information exchanged between the physician or other qualified healthcare professional and the patient during the course of the telemedicine service must be of an amount and nature that would be sufficient to meet the key components and/or requirements of the same service when rendered via face-to-face interaction.
Treatment must meet the same standard of care as, and be an appropriate substitute for, a face-to-face encounter.

Audio‑Only Approval & Temporary Telemedicine Allowances

Audio-only / Temporary Telemedicine Approval Status

Each code entry includes fields: Approved for Audio Only Visit, Temporarily allowed by Neighborhood through 12/31/2023, Permanent

Approved for Audio Only Visit = Yes (examples)

96160 — Administration of patient-focused health risk assessment instrument (Approved for Audio Only Visit = Yes; Permanent = X)
96161 — Administration of caregiver-focused health risk assessment instrument (Approved for Audio Only Visit = Yes; Permanent = X)
97802/97803/97804 — Medical nutrition therapy (Approved for Audio Only Visit = Yes; Permanent = X)
99199 — Unlisted special service (Doula services) (Approved for Audio Only Visit = Yes; Permanent = X)

Coding

Temporarily allowed via telemedicine through 2023-12-31CPT

77427	Radiation treatment management, 5 treatments
90953	ESRD related services monthly, patients <2 yrs, 1 face-to-face visit per month
90956	ESRD related services monthly, patients 2-11 yrs, 1 face-to-face visit per month

Permanently allowed via telemedicineCPTCovered

90785	Interactive complexity (list separately)
90951	ESRD monthly, patients <2 yrs, 4+ face-to-face visits
90952	ESRD monthly, patients <2 yrs, 2-3 face-to-face visits
90954	ESRD monthly, patients 2-11 yrs, 4+ face-to-face visits
90955	ESRD monthly, patients 2-11 yrs, 2-3 face-to-face visits
90957	ESRD monthly, patients 12-19 yrs, 4+ face-to-face visits
90958	ESRD monthly, patients 12-19 yrs, 2-3 face-to-face visits

Approved for Audio Only Visit = YesCPTCovered

90785	Interactive complexity (list separately)
99442	Telephone E/M 30-59 minutes
99443	Telephone E/M 60-89 minutes
99406	Smoking and tobacco use cessation counseling, intermediate
99407	Smoking and tobacco use cessation counseling, intensive
99408	Alcohol and/or substance abuse screening and brief intervention, 15-30 minutes
99409	Alcohol and/or substance abuse screening and brief intervention, >30 minutes
G0444	Annual alcohol misuse screening, 15 minutes
G9685	Behavioral health integration/related code (as applicable)

Approved for Audio Only Visit = NoCPTNot Covered

77427	Radiation treatment management, 5 treatments
90951	ESRD monthly, patients <2 yrs, 4+ face-to-face visits
90952	ESRD monthly, patients <2 yrs, 2-3 face-to-face visits
90953	ESRD monthly, patients <2 yrs, 1 face-to-face visit per month
90954	ESRD monthly, patients 2-11 yrs, 4+ face-to-face visits
90955	ESRD monthly, patients 2-11 yrs, 2-3 face-to-face visits
90956	ESRD monthly, patients 2-11 yrs, 1 face-to-face visit per month
90957	ESRD monthly, patients 12-19 yrs, 4+ face-to-face visits
90958	ESRD monthly, patients 12-19 yrs, 2-3 face-to-face visits

Permanently allowed (Permanent = X)CPTCovered

99305	Initial nursing facility care, typically 45 minutes
99307	Subsequent nursing facility care, typically 25 minutes
99308	Subsequent nursing facility care, typically 25 minutes (extended)
99309	Subsequent nursing facility care
99310	Subsequent nursing facility care, high complexity
99315	Nursing facility discharge day management
99316	Nursing facility discharge day management, extended
99318	Home visit, new patient
99324	Domiciliary/rest home visit, new patient
99325	Domiciliary/rest home visit, established patient

1–10 of 39

1/4

Temporarily allowed through 12/31/2023 = XCPT

99442	Telephone E/M 30-59 minutes (temporarily allowed as applicable)
99443	Telephone E/M 60-89 minutes (temporarily allowed as applicable)
99406	Smoking cessation counseling, intermediate (temporarily allowed)
99407	Smoking cessation counseling, intensive (temporarily allowed)
99408	Alcohol/substance abuse SBI, 15-30 min (temporarily allowed)
99409	Alcohol/substance abuse SBI, >30 min (temporarily allowed)
G0444	Annual alcohol misuse screening, 15 minutes (temporarily allowed)
G9685	Behavioral health integration/related code (temporarily allowed where noted)

Mixed/Other Codes Includedmixed

G0444	Annual alcohol misuse screening, 15 minutes
G9685	Behavioral health integration/related code

ModifiersModifier

95	Synchronous telemedicine service rendered via real-time interactive audio and video
CR	Catastrophe/disaster-related (temporary requirement for certain pandemic-era telemedicine allowances)

Place of service (POS) and modifier guidance: When the patient is located at home, POS 10 is acceptable; when the patient is at another originating site, POS 02 is appropriate. For telemedicine services rendered via real-time interactive audio and video, append modifier 95. For services temporarily allowed due to the COVID-19 public health emergency that the payer has designated as "temporarily allowed through 12/31/2023," include modifier CR in addition to modifier 95 as required until the temporary period ends. Telephone-only services must be filed with POS 02 or POS 10 as noted and follow the Approved for Audio Only Visit designation in the coding grid.

Provider Actions & Billing Requirements

Documentation Required

Medical record retention and support

Neighborhood may request medical records for any billed telemedicine/telephone service. Documentation must support the services billed and the medical necessity of those services, and Neighborhood follows CMS standards for proper documentation requirements.

Billing Rule

Claim submission and coding standards

All telemedicine claims must be submitted on a professional claim. Coding must follow CPT, ICD-10-CM and HCPCS Level II standards. Providers must submit claims within contractual timely filing guidelines.

Background

Background: The policy defines telemedicine/telehealth as real time, two-way synchronous audio, video, telephone-audio-only communications or electronic media used to provide clinical services. Medical necessity and coverage determinations reference external sources including NCD/LCD, industry-accepted criteria such as InterQual, and state guidance from Rhode Island EOHHS, and the policy is applied alongside Neighborhood's internal Clinical Medical Policies (CMPs). The policy purpose is to align coverage, coding and billing with external guidance and to document temporary COVID-19 era expansions (notably many codes temporarily allowed through 12/31/2023) while preserving standard medical necessity and documentation requirements.

Definitions / key terms

Telemedicine/Telehealth (definition)Real-time, two-way synchronous audio, video, telephone-audio-only communications or electronic media or other telecommunications technology used to provide clinical health-care services

Terminology noteTerms telemedicine and telehealth are used interchangeably

Medical necessity referencesNCD, LCD, InterQual, Rhode Island EOHHS, Clinical Medical Policies (CMP) used to determine medical necessity

Revision History

04/18/2023revised

Material: Removed preventative medicine services section effective 5/12/23; updated T1016 from telemedicine only to telemedicine & audio effective 7/1/23; added CPTs T1017 and H2000 to coding grid. Detail: Effective 7/1/23 changes to T1016 and additions to coding grid.

01/27/2023revised

Material: Updated coding section to clarify requirements, added Doula service CPTs to Coding Grid and allowed Established E/M codes for Audio Only for PCPs effective 7/1/22. Detail: Coding clarifications and Doula CPTs added; established E/M audio-only allowance for PCPs.

05/01/2022revised

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyTelemedicine/Telephone Services Payment Policy – Archive 3

Policy CodePolicy N/A

Change TypeRevisions and coding updates (2021–2023)

Effective Date

Next Review Date

Key ActionVerify patient eligibility and bill telemedicine claims with the specified POS/modifier rules and supporting documentation per CMS standards.

SourceLink

On This Page

Services must be within the provider's scope of license.

Audio-Only Visit Approval and Temporary Allowance Flags

Certain services are approved for audio-only (telephone) visits as indicated in the coding grid; providers must follow billing instructions for audio-only visits (POS and modifier requirements).
See coding section for 'Approved for Audio Only Visit' flags.
Additional services temporarily allowed to be performed via telemedicine or telephone due to the COVID-19 public health emergency are indicated in the coding grid and must be billed with CR modifier and appropriate POS when required. These temporary allowances are time-limited (see coding grid effective through 12/31/2023).
Check coding grid for 'Temporarily allowed by Neighborhood through 12/31/2023' flags and modifier/ POS requirements.

Coverage Limitations

The following subsequent visit limits apply:

ALL of the following

Subsequent hospital services are limited to 1 telehealth visit every 3 days.
Subsequent nursing facility care services are limited to 1 telehealth visit every 14 days.

Coverage Exclusions

Telemedicine/Telephone services are NOT covered when ANY of the following apply:

ANY of the following

Services rendered via e-mail or facsimile (fax).
Services rendered on social networking platforms including, but not limited to: Facebook, Twitch, TikTok.
Telemedicine/Telephone services delivered on the same day as a face-to-face visit by the same provider and for the same condition.
Patient communication incidental to an office visit, including, but not limited to: reporting of test results, provision of educational materials, patient follow-up calls or 'check-ins'.
Administrative services, including, but not limited to: scheduling, appointment reminders, medication refills, ordering of diagnostic or laboratory tests.
Telemedicine/Telephone services conducted by any office staff, RNs, LPNs.
Automated computer programs used to diagnose and/or treat ocular or refractive conditions.

Excluded Provider Types

ANY of the following

Acupuncture.
Ambulance service.
Ambulatory surgical facility.
Audiologist.
Certified registered nurse first assist.
Chiropractors.
Dental specialties.
Durable medical equipment supplier.
General hospital.
Home infusion.
Laboratory.
Pathology.
Pharmacy.
Psychiatric hospital.
Radiologists.
Rehabilitation hospital.
Renal/Dialysis facility.
Retail based clinic.
Skilled nursing facility.

99211-99215 (Established PCP E/M) — Approved for Audio Only Visit = Yes (PCP only); Permanent = X

99231-99233 — Subsequent hospital care (Approved for Audio Only Visit = Yes; Permanent = X)

99238/99239 — Hospital discharge day management (Approved for Audio Only Visit = Yes; Temporarily allowed = X)

Approved for Audio Only Visit = No (examples, many temporarily allowed through 12/31/2023)

97110/97112/97116 and many therapy/PT/OT procedure codes — Approved for Audio Only Visit = No; Temporarily allowed through 12/31/2023 = X
99281-99285 (ED visits), 99291-99292 (critical care) — Approved for Audio Only Visit = No; Temporarily allowed through 12/31/2023 = X
99304-99306 (Initial nursing facility) — Approved for Audio Only Visit = No; Temporarily allowed through 12/31/2023 = X
Many domiciliary/home visit and observation/inpatient codes — Approved for Audio Only Visit = No; some Temporarily allowed = X
Sample explicit code rows: 99281: No; Temporarily allowed = X; 99282: No; Temporarily allowed = X; 99283: No; Temporarily allowed = X; 99284: No; Temporarily allowed = X; 99285: No; Temporarily allowed = X

Per-code billing modifiers/place of service notes

Permanent telemedicine codes: use POS 10 when patient at home with modifier 95; or POS 02 with modifier 95 when patient not at home (per coding section)
Temporarily allowed codes through 12/31/2023: use POS 10 with modifiers 95 and CR when patient at home, or POS 02 with modifiers 95 and CR when patient not at home; telephone-only files require POS 02 and modifier CR or POS 10 and modifier CR

Per-code flags in the coding grid record three fields: Approved for Audio Only Visit (Yes/No), Temporarily allowed by Neighborhood through 12/31/2023 (marked X when temporarily allowed), and Permanent (marked X when permanently allowed). Interpret these flags literally: bill audio-only encounters only for codes with Approved for Audio Only Visit = Yes; codes with the temporary X may be billed as telemedicine/audio-only only through 12/31/2023; codes with Permanent = X indicate ongoing telemedicine approval as shown in the grid. Inclusion of a code in the policy does not by itself guarantee coverage — claims must meet medical necessity, documentation and other policy criteria.

Billing Rule

Place of Service and Modifiers for Permanent Telemedicine Codes

For permanent telemedicine codes: bill with Place of Service (POS) 10 when the patient is located at home and append modifier 95; bill with POS 02 when the patient is not at home and append modifier 95. Telephone-only services must be filed with POS 02 or POS 10 as specified by the code's audio-only designation.

Billing Rule

Place of Service and Modifiers for Temporary Telemedicine Codes (through 2023-12-31)

For codes temporarily allowed through 2023-12-31: when the patient is at home bill POS 10 with modifiers 95 and CR; when the patient is not at home bill POS 02 with modifiers 95 and CR. Telephone-only services for temporary allowances must be filed with POS 02 and modifier CR or POS 10 and modifier CR as specified.

Note

Reimbursement rate

Neighborhood reimburses telemedicine and telephone-only services that meet policy criteria at 100% of the in-office allowable amount.

Denial Risk

Eligibility and medical necessity verification

Verify patient eligibility, coverage and any required authorizations prior to rendering telemedicine/telephone services. Services that do not meet medical necessity or other policy criteria may be denied.

Billing Rule

Audio-only reporting constraints

Audio-only reporting constraints: only codes with 'Approved for Audio Only Visit = Yes' may be billed for audio-only encounters; codes marked 'No' should not be billed as audio-only.

Non-material: Combined Telemedicine and Temporary Telemedicine Policies and updated language/coding to align with CMS, EOHHS, OHIC guidance. Detail: Consolidation and alignment with external guidance.

01/20/2022revised

Non-material: Policy update to include new POS 10 per CMS effective 4/1/22. Detail: Policy update to include new POS 10 per CMS effective 4/1/22.

04/13/2021revised

Non-material: Formatting updates only. Detail: Formatting Updates. No content changes.