CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Assisted Living services reimbursement

Defines coverage and per-diem reimbursement, billing, documentation, and exclusions for Assisted Living services for Neighborhood Health Plan of Rhode Island members enrolled in the INTEGRITY for Duals (Fully Integrated D-SNP) product.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyAssisted Living services reimbursement

Policy CodePolicy N/A

Change TypeAdministrative and clarifying updates

Effective Date

Next Review Date

Key ActionVerify member eligibility, coverage, and authorization before providing services and follow the Assisted Living Clinical Medical Policy and Prior Authorization Reference page.

SourceLink

POLICY UPDATE CHANGES

Updated policy template to include new lines of business and added claim submission requirements and LTSS language (01/01/26).

Updated coverage exclusions to include correct level of care tier (06/09/25).

Incorporated RI Assisted Living Rate Reform Tier A/B (effective 11/01/21) and Tier C (effective 02/01/22) coding (03/16/22 historical update).

Per diemReimbursement basis

3Tiered levels of care

T2031, T2031-UB, T2031-UCPrimary billing codes listed

Assisted Living Coverage Criteria

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General coverage criteria overview

Assisted Living per-diem services are covered when ALL of the following conditions are met:

ALL of the following

Member is enrolled in INTEGRITY for Duals (Fully Integrated D-SNP).
Member has RI EOHHS-approved tier designation (Tier A, B, or C) and/or meets LTSS waiver requirements when applicable.
Services are provided in a residential community care facility and billed per member's approved tier.
Member is not concurrently enrolled in an Adult Day Health program for the same services.

What Providers Must Do

Prior Authorization

Verify eligibility, coverage and authorization

Provider must verify member eligibility, coverage and any required authorization prior to rendering Assisted Living services. See Neighborhood's plan-specific Prior Authorization Reference page and the Assisted Living Clinical Medical Policy for details and contact Provider Services for questions.

Documentation Required

Maintain treatment record and ISP

Create and maintain a treatment record for each member receiving Assisted Living services, including an Individual Service Plan (ISP) written by a registered nurse or certified assisted living administrator within seven (7) days after move-in; ensure ISP nurse review per state regulations and perform regular assessments and ISP reviews at least every 12 months or as the member's condition changes.

Member identification (Neighborhood ID, name)
Physician's order supporting need for skilled services
Member diagnosis
Initial admission assessment
Individual Service Plan (ISP) written by RN or certified assisted living administrator (within 7 days) including services/interventions, frequency and duration, responsible party, date and signature
ISP nurse review as required by state regulations
Documentation of regular member assessment (not to exceed 12 months) and ISP review (not to exceed 12 months)
Re-admission assessment, as required by state regulations

Billing Rule

Claim submission format and date span rules

Submit claims using the 837 Professional file format (CMS-1500). Date-span billing is permitted only when services were provided consecutively on each date within the span, dates of service are within the same month, and any break in service must be indicated on a new claim line. Providers must submit total billed charges including any member patient share.

Billing Rule

Submit claims per tier designation

Bill according to the member's RI EOHHS/DHS tier designation; Neighborhood may deny claims if the incorrect tier is submitted or does not match the member's RI EOHHS approval.

T2031
T2031-UB
T2031-UC

Documentation Required

Record amendments and audit access

All additions, deletions, modifications, or edits to established records must comply with Chapter 3 of the CMS Medicare Program Integrity Manual. Neighborhood may request copies of patient records at any time to validate billed services and medical necessity.

Billing Rule

Patient share handling

INTEGRITY for Duals members may have a monthly patient share as determined by RI EOHHS; patient share is applied and deducted from the allowed benefit amount at adjudication, but providers should submit claims with total billed charges that include the patient share.

Defined Terms

Definitions

Assisted LivingServices that maximize continued independence in a residential community care facility by providing supervision, security, and personalized assistance with activities of daily living; reimbursed on a per diem basis and delivered at one of three tiered levels of care.

ISP (Individual Service Plan)A care plan written by a registered nurse or certified assisted living administrator that documents services/interventions needed, frequency and duration, responsible party, and includes date and signature of the responsible RN or administrator; must be written within seven days after move-in.

INTEGRITY for DualsNeighborhood Health Plan of Rhode Island's Fully Integrated Dual Eligible Special Needs Plan (D-SNP) product to which this policy applies.

LTSS waiverLong-Term Services and Supports waiver; members without an LTSS waiver are excluded from this Assisted Living benefit unless otherwise eligible per policy and RI EOHHS rules.

Background and Scope

This policy defines Neighborhood Health Plan of Rhode Island's per-diem reimbursement and program requirements for Assisted Living services for members enrolled in INTEGRITY for Duals (Fully Integrated D-SNP). Assisted Living is reimbursed on a per diem basis and includes three tiered levels of care (Tier A, B, and C) with clinical criteria and tier assignments governed by RI EOHHS and the Neighborhood Assisted Living Clinical Medical Policy. Providers must verify eligibility, coverage, and authorization prior to rendering services and maintain required documentation, including an Individual Service Plan (ISP) completed by a registered nurse or certified assisted living administrator.

Policy Changes

2026-01-01administrativeLatest

Updated policy template to include new lines of business, added claim submission requirements, and incorporated LTSS language (administrative/template and content consolidation).

2025-06-09coverage_exclusion_clarification

Updated coverage exclusions to include the correct level of care tier.

2022-03-16coding/tier_mapping_added (historical)

Incorporated RI Assisted Living Rate Reform tier coding updates (Tier A/B effective 11/01/21 and Tier C effective 02/01/22); coding and tier language added historically.

Operational Notes and Provider Contact

Per the provider contract, rates are inclusive of all services specified in the contract and reimbursements are made on a per-diem basis.

The inclusion of a HCPCS code in this policy (for example, T2031, T2031-UB, T2031-UC) does not guarantee payment; coding must align with the member's RI EOHHS tier designation and applicable coding standards.

All claims payments are subject to member eligibility, the provider contract, required authorizations, claim edit rules, and applicable state and federal regulations; submission of a code or claim alone does not ensure reimbursement.

Contact Information

Provider Services Phone1-800-963-1001

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyAssisted Living services reimbursement

Policy CodePolicy N/A

Change TypeAdministrative and clarifying updates

Effective Date

Next Review Date

Key ActionVerify member eligibility, coverage, and authorization before providing services and follow the Assisted Living Clinical Medical Policy and Prior Authorization Reference page.

SourceLink

On This Page

OpenPayer

Assisted Living services reimbursement

Assisted Living Coverage Criteria

Relevant Billing Codes

What Providers Must Do

Billing Notes and Coverage Exclusions

Defined Terms

Background and Scope

Key Timeframes and Thresholds

Policy Changes

Operational Notes and Provider Contact

T2031	Assisted living, Tier A Facility
T2031-UB	Assisted living, Tier B Facility
T2031-UC	Assisted living, Tier C Facility

Assisted Living services reimbursement

Assisted Living Coverage Criteria

Relevant Billing Codes

What Providers Must Do

Billing Notes and Coverage Exclusions

Defined Terms

Background and Scope

Key Timeframes and Thresholds

Other Policies to Read

Policy Changes

Operational Notes and Provider Contact