CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Telemedicine Services Payment Policy 04.18.2025

Defines Neighborhood Health Plan of Rhode Island coverage, limitations, exclusions, billing, documentation, and reimbursement rules for synchronous telemedicine/telehealth and telephone-only services across Medicaid (excluding EFP), Integrity, and Commercial lines.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyTelemedicine Services Payment Policy 04.18.2025

Policy CodePolicy N/A

Change TypeCoding grid and modality clarifications (multiple revisions)

Effective Date04/18/2025

Next Review DateN/A

Key ActionVerify eligibility/authorization and submit professional claims using the policy coding grid and required POS/modifier rules, maintaining documentation of medical necessity.

SourceLink

POLICY UPDATE CHANGES

04/18/2025: Updated coding grid for January 2025 code load.

07/01/2024: Updated coding grid to show 99441-99443 as audio only, N/A for audio/visual.

01/01/2024: Updated coding section to align with CMS and EOHHS guidance; removed section on waiving cost share for 99211 and 99212.

04/18/2023: Removed preventative medicine services section effective 5/12/23 and updated several codes (T1016, T1017, H2000 additions).

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

100%Reimbursement rate for telemedicine-only services

1 per 3 days

Hospital telehealth subsequent visit limit

1 per 14 daysNursing facility telehealth subsequent visit limit

2022-04-01POS 10 acceptance date

04/18/2025Most recent coding grid update

Coverage Summary

This policy defines Neighborhood Health Plan of Rhode Island coverage, limitations, exclusions, billing, documentation, and reimbursement rules for synchronous telemedicine/telehealth and telephone-only services across Medicaid (excluding EFP), INTEGRITY, and Commercial lines. Coverage stance: covered_with_criteria. Policy status: CURRENT. Effective/last reviewed metadata and document history include updates such as 04/18/2025: Updated coding grid for January 2025 code load and prior material changes (e.g., coding updates effective 07/01/2024 and 01/01/2024).

Telemedicine key stats and scope

Reimbursement rate100% of in‑office allowable

Hospital subsequent visit limit1 telehealth visit per 3 days

Nursing facility subsequent visit limit1 telehealth visit per 14 days

POS 10 acceptance dateNeighborhood began accepting POS 10 on 2022-04-01

Most recent coding grid update04/18/2025 (January 2025 code load)

Approximate CPT count~160 codes listed

Audio‑Only availabilityAudio‑Only allowed for a subset of codes (many codes approved)

Medical Necessity & Coverage Criteria

General Coverage Criteria

Telemedicine/Telephone Services are covered when ALL of the following criteria 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 exchanged must be of an amount and nature sufficient to meet the key components and/or requirements of the same service when rendered face-to-face
Treatment must meet the same standard of care as, and be an appropriate substitute for, a face-to-face encounter

Coding Grid & Billing Rules

Telemedicine/Telehealth CPT codes with modality approvalCPTCovered

77427	Radiation treatment management, 5 treatments; Approved for Audio/Visual Visit: Yes; Approved for Audio Only Visit: No
90785	Interactive complexity; Approved for Audio/Visual Visit: Yes; Approved for Audio Only Visit: Yes
90845	Psychoanalysis; Approved for Audio/Visual Visit: Yes; Approved for Audio Only Visit: Yes
90951	ESRD related services monthly (<2 yrs) with 4+ face-to-face visits per month; AV: Yes; Audio only: No
90952	ESRD related services monthly (<2 yrs) with 2-3 face-to-face visits per month; AV: Yes; Audio only: No
90953	ESRD related services monthly (<2 yrs) with 1 face-to-face visit per month; AV: Yes; Audio only: No
90954	ESRD related services monthly (2-11 yrs) with 4+ face-to-face visits per month; AV: Yes; Audio only: No
90955	ESRD related services monthly (2-11 yrs) with 2-3 face-to-face visits per month; AV: Yes; Audio only: No
90956	ESRD related services monthly (2-11 yrs) with 1 face-to-face visit per month; AV: Yes; Audio only: No
90957	ESRD related services monthly (12-19 yrs) with 4+ face-to-face visits per month; AV: Yes; Audio only: No

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Place of Service / Modifiers rulesmixed

POS 10 / POS 02 / modifier 95

Claims for AV telemedicine: use POS 10 when patient at home and modifier 95; or POS 02 when patient not at home and modifier 95. Claims for telephone-only must be filed with POS 02 or 10 and no modifier.

Telemedicine/Telehealth CPT codes with modality approvalCPTCovered

97153	Adaptive behavior treatment by protocol, administered by technician under the direction of a physician or other qualified health care professional, face-to-face with two or more patients, each 15 minutes.
97154	Group adaptive behavior treatment by protocol, administered by technician under the direction of a physician or other qualified health care professional, face-to-face with two or more patients, each 15 minutes.
97155	Adaptive behavior treatment with protocol modification, administered by physician or other qualified health care professional, which may include simultaneous direction of technician, face-to-face with one patient, each 15 minutes.
97156	Family adaptive behavior treatment guidance, administered by physician or other qualified health care professional (with or without the patient present), face-to-face with guardian(s)/caregiver(s), each 15 minutes.
97157	Multiple-family group adaptive behavior treatment guidance, administered by physician or other qualified health care professional (without the patient present), face-to-face with multiple sets of guardians/caregivers, each 15 minutes.
97158	Group adaptive behavior treatment with protocol modification, administered by physician or other qualified health care professional, face-to-face with multiple patients, each 15 minutes.
97161	Physical therapy evaluation: low complexity; typically 20 minutes.
97162	Physical therapy evaluation: moderate complexity; typically 30 minutes.
97163	Physical therapy evaluation: high complexity; typically 45 minutes.
97164	Re-evaluation of physical therapy established plan of care; typically 20 minutes.

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Billing Rule

Place of service and modifier requirements

For audio/visual telemedicine visits, bill with Place of Service (POS) 10 when the patient is located at home and include modifier 95; alternatively bill with POS 02 when the patient is not at home and include modifier 95. Telephone-only visits must be filed with POS 02 or POS 10 and should not include a modifier.

POS 10 when patient at home + modifier 95
POS 02 when not at home + modifier 95
Telephone-only filed with POS 02 or 10 and no modifier

Billing Rule

Report telemedicine modality per code

Report the CPT/HCPCS procedure code along with the visit modality per the policy coding grid. Each listed code indicates whether it is approved for Audio/Visual visits and/or Audio Only visits; billing must reflect the approved modality for the specific code.

Provider Actions & Requirements

Documentation Required

Medical record documentation

Maintain documentation that supports the services billed and the medical necessity. Neighborhood may request medical records to substantiate billed services and follows CMS standards for proper documentation.

Neighborhood may request medical records and follows CMS documentation standards.

Prior Authorization

Verify prior authorization and eligibility

Verify member eligibility, coverage and any required authorizations before providing services. Providers should consult Neighborhood's plan-specific Prior Authorization Reference page and applicable Clinical Medical Policies for authorization requirements.

Check plan-specific Prior Authorization Reference and Clinical Medical Policies

Background & Definitions

Telemedicine/telehealth (terms used interchangeably) is defined as real-time, two-way synchronous audio, video, telephone-audio-only communications or electronic media or other telecommunications technology used to facilitate assessment, diagnosis, counseling, prescribing treatment, and care management while the patient is at an originating site and the provider is at a distant site.

Telemedicine/Telehealth: Real time, two-way synchronous audio, video, telephone-audio-only communications or electronic media or other telecommunications technology used to provide or support healthcare delivery.

Revision History

04/18/2025revisedLatest

04/18/2025: Updated coding grid for January 2025 code load.

07/01/2024clarified

07/01/2024: Updated coding grid to show 99441-99443 as audio only, N/A for audio/visual.

01/01/2024revised

01/01/2024: Updated coding section to align with CMS and EOHHS guidance; removed section on waiving cost share for 99211 and 99212.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyTelemedicine Services Payment Policy 04.18.2025

Policy CodePolicy N/A

Change TypeCoding grid and modality clarifications (multiple revisions)

Effective Date04/18/2025

Next Review DateN/A

Key ActionVerify eligibility/authorization and submit professional claims using the policy coding grid and required POS/modifier rules, maintaining documentation of medical necessity.

SourceLink

On This Page

Services must be within the provider's scope of license

Services must comply with Rhode Island laws, OHIC rules, and State of Rhode Island government program contracts

Coverage Limitations (Subsequent Visit Frequency)

ALL of the following

Subsequent visit frequency limits: Subsequent hospital services are limited to 1 telehealth visit every 3 days1 per 3 days
Applies to subsequent hospital telehealth services
Subsequent visit frequency limits: Subsequent nursing facility care services are limited to 1 telehealth visit every 14 days1 per 14 days
Applies to subsequent nursing facility telehealth services

Coverage Exclusions

ANY of the following

Excluded modality: Services rendered via e-mail or facsimile (fax)
Excluded modality: Services rendered on social networking platforms (e.g., Facebook, Twitch, TikTok)
Excluded duplication: Telemedicine/Telephone services delivered on the same day as a face-to-face visit by the same provider for the same condition
Incidental communications: Patient communication incidental to an office visit (e.g., reporting of test results, provision of educational materials, patient follow-up calls or 'check-ins')
Administrative services (e.g., scheduling, appointment reminders, medication refills, ordering of diagnostic or laboratory tests)
Staff-delivered services: Telemedicine/Telephone services conducted by office staff, RNs, LPNs
Automated program exclusion: Automated computer programs used to diagnose and/or treat ocular or refractive conditions

Excluded Provider Types

It is not medically appropriate or reasonable for the following provider types to provide any Telephone and/or Telemedicine services:

ANY of the following

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

Use coding grid for telemedicine modality

Billing Rule

Claim submission and timeliness; Professional claim requirement

Submit complete professional claims within the contractual timely filing guidelines. Coding must adhere to AMA CPT, ICD-10-CM, and HCPCS Level II standards. All telemedicine services must be billed on a professional claim.

File within contractual timely filing limits
Follow AMA CPT / ICD-10-CM / HCPCS Level II coding standards
Bill telemedicine services on professional claims

Billing Rule

Do not report prohibited code combinations for prolonged services

Do not report prohibited combinations for prolonged services and follow the code-specific guidance for units. Codes listed as prolonged services must not be reported with specified other prolonged-service codes on the same date and must not be reported for units less than the code's defined minimum (typically 15 minutes).

Prolonged-service codes: G0316, G0317, G0318, G2212, G0513, G0514
Do not report prohibited combinations (see coding guidance)
Do not report units less than the code's minimum time (e.g., less than 15 minutes for listed prolonged codes)

Documentation Required

Claims subject to audit and eligibility checks

Payments are subject to member eligibility, correct coding and documentation, required authorizations, provider contract terms, and applicable state and federal regulations. All services billed are subject to audit.

Claims are subject to eligibility, coding/documentation, authorizations, provider contracts, regulations, and audit

04/18/2023revised

04/18/2023: Removed preventative medicine services section effective 5/12/23 and updated several codes (T1016, T1017, H2000 additions).

01/27/2023clarified

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