CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Temporary expansion of telemedicine and telephone-only services

Temporary policy expanding coverage and reimbursement for clinically appropriate, medically necessary telemedicine and telephone-only services for Neighborhood Health Plan of Rhode Island members during the COVID-19 emergency, affecting Medicaid, INTEGRITY, and Commercial lines.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyTemporary expansion of telemedicine and telephone-only services

Policy CodePolicy N/A

Change TypeTemporary policyoperational clarifications

Effective DateMar 18, 2020

Next Review DateN/A

Key ActionPrior authorization requirements are waived for the telemedicine/telephone-only services described; providers must still verify eligibility and coverage for other services.

SourceLink

POLICY UPDATE CHANGES

Language added regarding Neighborhood's ability to implement, modify, and terminate this temporary policy without the normal sixty-day contractual notification.

Documentation requirements and cost share waiver requirements were updated.

100%Reimbursement rate of telemedicine/telephone encounters relative to in-office allowable

POS 02Place of Service code required on claims for telemedicine/telephone-only

CRRequired claim modifier (Catastrophe/Disaster Related)

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Coverage Criteria for Telemedicine and Telephone-only Services

General coverage criteria

Telemedicine/telephone-only services are covered when ALL of the following are met

Telemedicine coverage criteria: The patient is present/participates at the time of service.

Telemedicine coverage criteria: Services must be of an amount and nature sufficient to meet the key components and/or requirements of the same service when rendered via face-to-face interaction.

Telemedicine coverage criteria: Services must be medically necessary and otherwise covered under the member's benefit plan.

Telemedicine coverage criteria: Services must be within the provider's scope of license.

Telemedicine coverage criteria: A permanent record of the telemedicine/telephone-only communication(s) must be documented and maintained as part of the patient's medical record.

Documentation requirements for telemedicine/telephone-only services are the same as for face-to-face encounters.

Permitted providers

Temporarily allowed provider types (when services meet the general coverage criteria):

Allowed provider types: Primary care physicians; All Medical Specialists (defined as any MD, DO, NP, PA); Optometrists; Doctors of Podiatric Medicine (DPM); Chiropractors (DC); Lactation Consultants; Physical, Occupational and Speech Therapists; Diabetes Educators; Nutritionists; Midwives; Urgent Care Centers; Emergency Departments; Retail Based Clinics.

Per policy list; providers may deliver services regardless of patient originating site per OHIC Bulletin 2020-01.

Services transmitted solely via email, text message, fax, or patient portal are specifically listed as exclusions and are not reimbursable under this temporary telemedicine/telephone-only policy. Additionally, when a telemedicine visit is performed by the same provider for the same condition on the same day as a face-to-face visit, that telemedicine encounter is excluded from coverage.

For claims processing, telemedicine is treated as a place-of-service benefit (see coding section). Providers should not substitute asynchronous patient messages (email/text/portal/fax) for a reimbursable telemedicine encounter and should avoid billing for telephone or synchronous telemedicine visits that are duplicative of an in-person visit by the same provider on the same date for the same condition.

Certain services are explicitly identified as not clinically appropriate to bill via telemedicine or telephone. Examples include hands-on treatments such as chiropractic manual manipulation and physical therapy manual therapy, which require in-person, hands-on care and therefore are excluded from telemedicine/telephone reimbursement.

Other exclusions include encounters conducted by office staff or non-billing clinical personnel (for example, RNs or LPNs performing telephonic contacts), and routine administrative or incidental patient communications (scheduling, registration, medication refill requests, reporting test results, patient-completed history intake, etc.), which are not billable as telemedicine services.

Claim Placement, Modifiers, and Coding Requirements

Claim placement and modifiermixed

POS 02	Place of Service code indicating telemedicine/telephone-only
CR	Modifier: Catastrophe/Disaster Related

Provider Actions, Prior Authorization, and Documentation

Prior Authorization

Prior Authorization Waiver

Prior authorization requirements will be waived for the telemedicine/telephone-only services outlined in this policy. Providers should still verify member eligibility, coverage and any plan-specific prior authorization references prior to rendering services.

Telemedicine/telephone-only services listed in this policy (see coverage criteria).
Contact Provider Services at 1-800-963-1001 with questions.

Note

Medical Necessity References

All services must be medically necessary to qualify for reimbursement. Neighborhood may use National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs), industry-accepted criteria such as InterQual, EOHHS recommendations, and Neighborhood's Clinical Medical Policies to determine medical necessity. It is the provider's responsibility to verify eligibility, coverage and authorization criteria prior to rendering services.

Definitions

Telemedicine/telephone-only service — definition of remotely delivered clinically appropriate covered health service

DefinitionAny clinically appropriate, medically necessary covered health service delivered remotely where the patient is present and participates at the time of service and a permanent record of the telemedicine/telephone-only communication is created and maintained in the patient's medical record.

Key coverage conditionsServices must be sufficient in amount and nature to meet the key components/requirements of the same service when rendered face-to-face; must be within the provider's scope of license; and must be medically necessary and otherwise covered under the member's benefit plan.

Patient participationThe patient must be present and participate at the time of service.

DocumentationA permanent record of the telemedicine/telephone-only communication(s) must be documented and maintained as part of the patient’s medical record; documentation requirements are the same as for face-to-face encounters.

ReimbursementNeighborhood will reimburse telemedicine/telephone encounters at 100% of the in-office allowable for any clinically appropriate, medically necessary covered health service.

Background and Scope

This temporary policy was implemented to expand remote delivery of clinically appropriate, medically necessary services to support social distancing during the COVID-19 emergency. Its purpose is to allow covered telemedicine and telephone-only services when those services meet the policy's coverage criteria and are within the provider's scope of license.

The expansion is time-limited and operational in nature; it clarifies which modalities and service types are permitted versus excluded during the emergency period, and it supplements normal billing rules to enable remote care while preserving requirements that services be sufficient in amount and nature to meet the key components of the equivalent face-to-face service.