CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Gene Therapy Products — Reimbursement and Billing Requirements

Defines reimbursement and billing requirements for gene therapy products administered to Neighborhood Health Plan of Rhode Island members across Medicaid (excluding EFP), INTEGRITY, and Commercial lines of business.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyGene Therapy Products — Reimbursement and Billing Requirements

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit required authorization documentation to the pharmacy department prior to administration to avoid claim non-payment.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3Lines of business covered

authorizationPrior authorization may be required

recordsPlan may request medical records

cost sharingCommercial cost sharing

excludedInvestigational uses not covered

Coverage criteria for gene therapy products

Covered when ALL of the following conditions are met:

Medical necessity: therapy is medically necessary; plan may reference NCDs, LCDs, Interqual, EOHHS, Clinical Medical Policies, standard compendia, or other internal criteria to determine necessity.

Therapy is used for a medically accepted indication as defined by recognized standard reference compendia (e.g., AHFS-DI, Thomson Micromedex DrugDex, Clinical Pharmacology, Wolters Kluwer Lexi-Drugs) or peer-reviewed published medical literature supporting the use.

If prior authorization is required, additional documentation must be submitted to the pharmacy department for review prior to administration; failure to submit accurate HCPCS codes, units, or required clinical documentation may result in non-payment.

Claims submission requirements: the administering facility/provider must submit the claim after the entire dose/infusion has been administered to the member, and claims must follow applicable CPT/ICD-10-CM/HCPCS and contractual timely filing guidelines.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyGene Therapy Products — Reimbursement and Billing Requirements

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit required authorization documentation to the pharmacy department prior to administration to avoid claim non-payment.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Provider actions: authorization, documentation, and claims submission

Documentation Required

Prior authorization and documentation

For gene therapies that require an authorization, additional documentation must be submitted to the pharmacy department for review prior to administration. Clinical medical policies and required documentation guidance are available at: https://www.nhpri.org/providers/policies-andguidelines/clinical-medical-policies/. Failure to submit accurate HCPCS codes, units, or requested clinical documentation may result in non-payment.

Submit required additional clinical documentation to the pharmacy department when prior authorization is required.
Provide accurate HCPCS codes and units on all submissions.

Billing Rule

Claim submission and coding standards

Providers must submit complete claims for payment within contractually determined timely filing guidelines. Coding must follow current standards: CPT (AMA CPT Editorial Panel), ICD-10-CM, and HCPCS Level II. Billable services are subject to contractual agreements when applicable. Failure to submit complete claims or to use appropriate CPT/ICD-10/HCPCS coding may result in denial or non-payment.

Submit complete claims including all required fields and supporting documentation per contract and payer instructions.
Use appropriate CPT codes (per AMA CPT), ICD-10-CM diagnosis codes, and HCPCS Level II procedure/drug codes.
Ensure units, modifiers, and HCPCS descriptors accurately reflect services and quantities billed.

Billing Rule

Timing of claim submission

The administering facility/provider must submit the claim after the entire dose/infusion has been administered to the member.

Do not submit claims prior to completion of the full dose/infusion.
For multi-dose or staged administrations, submit claim only after the full treatment as defined by the authorization has been completed.

Key definitions

Investigational use — definition and implications

DefinitionTherapies used at a dose or for a condition other than those recognized as medically accepted indications per standard reference compendia are considered investigational.

Standard reference compendiaAmerican Hospital Formulary Service Drug Information (AHFS-DI); Thomson Micromedex DrugDex; Clinical Pharmacology; Wolters Kluwer Lexi-Drugs; peer-reviewed published medical literature supporting sufficient evidence.

Coverage consequenceNeighborhood does not provide coverage for drugs when used for investigational purposes.

Related policyRefer to the Clinical Trials Payment Policy for additional information on investigational use and coverage of trial-related services.

Application contextApplies to gene therapy products billed to Neighborhood Health Plan of Rhode Island when used outside medically accepted indications.

OpenPayer

Gene Therapy Products — Reimbursement and Billing Requirements

Coverage criteria for gene therapy products

Required coding systems

Provider actions: authorization, documentation, and claims submission

Key definitions