CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Telemedicine/Telehealth Services Coverage

Defines coverage, prerequisites, limitations, exclusions, eligible lines of business, billing and coding, documentation, reimbursement, and provider/member responsibilities for telemedicine/telephone services for Neighborhood Health Plan of Rhode Island (applies to Medicaid excluding EFP, INTEGRITY, and Commercial).

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyTelemedicine/Telehealth Services Coverage

Policy CodePolicy N/A

Change TypeMultiple coding updates and policy revisions (see changes list)

Effective DateN/A

Next Review DateN/A

Key ActionProviders must maintain documentation that supports services billed and medical necessity; Neighborhood may request medical records and follows CMS documentation standards.

POLICY UPDATE CHANGES

09/01/2025: Added Behavioral Health coding.

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

12/11/2024: Annual Policy Review Date.

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

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

04/18/2023: Policy Revision: Removed preventative medicine services section effective 5/12/23. Effective 7/1/23: Updated T1016 from telemedicine only to telemedicine & audio. 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: Combine Telemedicine and Temporary Telemedicine Policies and update language/coding to align with current 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.

04/13/2020: Update: Add code Q3014.

03/03/2020: Policy update, added Medicaid wording, Medicare coding, and format change.

12/31/2018: Policy Effective.

100%Reimbursement Rate vs In-office

Hospital telehealth visit frequency limit

1 per 14 daysNursing facility telehealth visit frequency limit

MultipleCPT codes listed as approved for telemedicine

SubsetApproved for Audio-Only

9Listed HCPCS/T Codes in this part

Coverage Summary

This policy defines coverage for Telemedicine/Telehealth Services — terms used interchangeably to include real-time synchronous audio/video, telephone audio-only, remote patient monitoring and other telecommunications technologies — and describes prerequisites, limits, exclusions, billing, and provider responsibilities applicable to Neighborhood Health Plan of Rhode Island. The policy applies to the following lines of business: Medicaid (excluding EFP), INTEGRITY, and Commercial. Neighborhood will reimburse telemedicine/telephone-only services at 100% of the in-office allowable for services meeting the policy criteria.

Key Facts

Reimbursement Rate100% of in‑office allowable

Hospital telehealth frequency limit1 per 3 days

Nursing facility telehealth frequency limit1 per 14 days

Scope / Lines of BusinessMedicaid (excl. EFP), INTEGRITY, Commercial

Medical‑Necessity Criteria

General Coverage Criteria

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

Patient present: The patient must be present at the time of service
Medical necessity: Services must be medically necessary and clinically appropriate to be provided through telemedicine
Sufficient communication: 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
Standard of care: Treatment must meet the same standard of care as, and be an appropriate substitute for, a face-to-face encounter

Modality & Code‑Level Approval

Telemedicine modality approval (per code)

Each listed code includes Line of Business and modality approvals. A code is approved for Audio/Visual Visit = Yes/No and Approved for Audio Only Visit = Yes/No as specified.

Telemedicine modality approval (per code): Each listed CPT/HCPCS/H code in the policy includes Line of Business and flags indicating whether it is approved for Audio/Visual Visit = Yes/No and Approved for Audio Only Visit = Yes/No.

Use code-level flags to determine modality billing

Telemedicine/Audio-Visual/Audio Only Approval by Code

Each listed code is approved or not approved for Audio/Visual and Audio Only visits as specified:

Code examples (operational guidance)

T1016
- Audio/Visual:

Coding

Unsupported block type: object

Provider Actions & Billing Rules

Documentation Required

Medical record documentation

Providers must maintain medical record documentation that supports the services billed and the medical necessity of those services. Neighborhood may request medical records for any service billed. Documentation must support the service(s) billed and medical necessity, and Neighborhood follows CMS standards for proper documentation requirements.

Billing Rule

Claim submission and coding standards

All telemedicine claims must be billed on a professional claim, submitted within contractually determined timely filing guidelines, and use CPT, ICD-10-CM, and HCPCS coding standards.

Definitions & Background

This policy outlines the scope of covered telemedicine/telehealth services and uses the terms telemedicine and telehealth interchangeably to include real-time two-way synchronous audio/video communications, telephone audio-only, remote patient monitoring, and other telecommunications technologies used to facilitate assessment, diagnosis, counseling, prescribing and care management. It applies to services for Medicaid excluding EFP, INTEGRITY, and Commercial lines of business and includes specific billing instructions, place-of-service/modifier requirements and a detailed coding grid that indicates, per code, whether a service is approved for Audio/Visual and/or Audio Only modality. Neighborhood reimburses covered telemedicine/telephone-only services at 100% of the in-office allowable when all policy criteria are met.

Telemedicine/Telehealth (definition)

Telemedicine/Telehealth (definition): Real time, two-way synchronous audio, video, telephone-audio-only communications or electronic media or other telecommunications technology facilitating assessment, diagnosis, counseling, prescribing treatment, and care management while patient is at an originating site and provider is at a distant site.

Terms telemedicine and telehealth used interchangeably

Revision History

09/01/2025MaterialLatest

Added Behavioral Health coding.

04/18/2025Material

Updated coding grid for January 2025 code load.

12/11/2024clarified

Annual Policy Review Date.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyTelemedicine/Telehealth Services Coverage

Policy CodePolicy N/A

Change TypeMultiple coding updates and policy revisions (see changes list)

Effective DateN/A

Next Review DateN/A

Key ActionProviders must maintain documentation that supports services billed and medical necessity; Neighborhood may request medical records and follows CMS documentation standards.

On This Page

Provider scope: Services must be within the provider's scope of license

title": "General Coverage Criteria"}

Coverage Limitations

Limits on frequency of telehealth visits:

Hospital subsequent services limit: Subsequent hospital services are limited to 1 telehealth visit every 3 days1 per 3 days
Nursing facility subsequent services limit: Subsequent nursing facility care services are limited to 1 telehealth visit every 14 days1 per 14 days

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Coverage Exclusions

Services NOT covered when delivered via telemedicine/telephone:

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

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Excluded Provider Types

The following provider types are considered not medically appropriate to provide Telephone and/or Telemedicine services (may not be exhaustive):

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

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Approved for Audio/Visual Visit = Yes

Audio Only: Approved for Audio Only Visit = Yes

T1019

Audio/Visual: Approved for Audio/Visual Visit = Yes
Audio Only: Approved for Audio Only Visit = No

90791

Audio/Visual: Approved for Audio/Visual Visit = Yes
Audio Only: Approved for Audio Only Visit = Yes

77427

Audio/Visual: Approved for Audio/Visual Visit = Yes
Audio Only: Approved for Audio Only Visit = No

Billing Rule

Place of Service and Modifiers for Telemedicine/Audio-Visual

For audio/visual visits: when the patient is at home file with place of service 10 and modifier 95; when the patient is not at home file with place of service 02 and modifier 95. For telephone-only visits: file with place of service 02 or 10 and do not include a modifier.

Prior Authorization

Verify eligibility and prior authorization

Providers are responsible to verify member eligibility, coverage, and any required prior authorization before rendering services. Refer to Neighborhood's Prior Authorization Reference page and Clinical Medical Policies for details.

Billing Rule

Reimbursement rate

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

Billing Rule

Report modality with each telemedicine claim

Providers must report the telemedicine modality (audio/visual vs audio-only) with each telemedicine claim. Claims will be adjudicated according to the policy's per-code 'Approved for Audio/Visual Visit' and 'Approved for Audio Only Visit' flags.

Billing Rule

Report modality per code

Only bill a service as audio-only when the specific CPT/HCPCS code's 'Approved for Audio Only Visit' flag is Yes; otherwise bill using audio/visual (with appropriate POS/modifier) or in-person coding as applicable.

Documentation Required

Line of Business-specific billing

Use the specified Line of Business when billing codes that have LOB restrictions. Examples include: 99495 and 99496 (Line of Business = INTEGRITY); G0466, G0467, G0468 (Line of Business = INTEGRITY & Commercial); many H-codes (for example H0001, H0004 are Line of Business = Medicaid; H0019 and others specify Medicaid and/or INTEGRITY).

Billing Rule

Use modality approval per code

When billing the listed T/HCPCS codes (T1016, T1017, T1019, T1023, T1024, T1027, T1031, T2017, T2021), follow the policy's modality approvals for each code. The policy lists these T-codes and their Approved for Audio/Visual and Approved for Audio Only flags that determine whether audio-only billing is allowed.

Documentation Required

Claims subject to audit and eligibility checks

Claims are subject to member eligibility checks, claims payment edits, coding and documentation guidelines, authorization policies, provider contract agreements, and state and federal regulations. All services billed are subject to audit.

07/01/2024Material

Policy Update: updated coding grid to show 99441-99443 as audio only, N/A for audio/visual.

01/01/2024Material

Policy Revision: Updated coding section to align with CMS and EOHHS guidance, removed section on waiving cost share for 99211 and 99212.

04/18/2023Material

Policy Revision: Removed preventative medicine services section effective 5/12/23. Effective 7/1/23: Updated T1016 from telemedicine only to telemedicine & audio. Added CPTs T1017 and H2000 to coding grid.

01/27/2023Material

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.

05/01/2022Material

Policy Update & Review: Combine Telemedicine and Temporary Telemedicine Policies and update language/coding to align with current CMS, EOHHS, OHIC guidance.

01/20/2022Material

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

04/13/2021clarified

Formatting Updates. No content changes.

04/13/2020Material

Update: Add code Q3014.

03/03/2020Material

Policy update, added Medicaid wording, Medicare coding, and format change.

12/31/2018Material

Policy Effective.