CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Multiple procedure reductions (payment rules)

Defines Neighborhood Health Plan of Rhode Island's coverage and payment requirements for multiple procedure reductions for providers billing Medicaid (excluding EFP), INTEGRITY, and Commercial lines of business.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyMultiple procedure reductions (payment rules)

Policy CodePolicy N/A

Change TypeAnnual reviews and clarifications

Effective DateNov 2, 2020

Next Review DateN/A

Key ActionVerify member eligibility, coverage and authorization criteria prior to rendering services; contact Provider Services at 1-800-963-1001 for details.

SourceLink

POLICY UPDATE CHANGES

08/01/2023 Annual Policy Review: Updated modifier 50/51 language.

10/01/2022 Annual Policy Review: Removed distinct services modifier language and referred to modifier policy.

03/11/2022 Updated language for Non-ASC services.

100%highest allowed procedure reimbursed at

50%second procedure reimbursed at

25%third–fifth procedures reimbursed at

sixth+sixth and additional procedures

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.

Multiple Procedure Payment Rules

Multiple procedure reimbursement rules

Neighborhood reimburses multiple procedures according to specified percentage reductions depending on facility and line of business.

ASC reimbursement (Medicaid & Commercial)

The procedure with the highest allowed amount reimbursed at 100% of the contracted rate
The procedures with the second, third, fourth, and fifth highest allowed amounts reimbursed at 50% of the contracted rate
The sixth and any additional procedures are considered global and will not be separately reimbursed

Non-ASC reimbursement (Medicaid & Commercial)

The procedure with the highest allowed amount reimbursed at 100% of the contracted rate
The procedure with the second highest allowed amount reimbursed at 50% of the contracted rate
The procedures with the third, fourth, and fifth highest allowed amounts reimbursed at 25% of the contracted rate
The sixth and any additional procedures are considered global and will not be separately reimbursed

INTEGRITY line

Reimbursed according to Medicare reduction rules

Modifiers, Codes, and Reimbursement Tiers

Modifiers and coding standardsModifier

Modifier 50	Used for bilateral procedures; report on single claim line with unit=1. Do not use when CPT/HCPCS description already specifies bilateral.
Modifier 51	Used to report additional procedures by the surgeon on the same day (multiple procedure reduction rules apply).
RT/LT	Do not report bilateral procedures with RT and LT on two separate lines instead of modifier 50.

Reimbursement tiers — quick reference (ASC vs Non-ASC)

ASC — highest procedure100% of contracted rate

ASC — 2nd through 5th procedures50% of contracted rate

ASC — 6th and additional proceduresNot separately reimbursed (considered global)

Pre-billing and Billing Actions

Prior Authorization

Pre-billing verification: confirm eligibility, coverage, and authorization

Verify member eligibility, coverage, and any required authorizations before rendering services. Contact Provider Services for details and to confirm member-specific requirements.

Providers are responsible for verifying eligibility, coverage and authorization criteria prior to rendering services.
For assistance or to confirm authorization requirements, call Provider Services at 1-800-963-1001.

Key Terms and Modifier Sequencing

Multiple procedures — definition

DefinitionMultiple procedures are separate procedures performed by a single physician or physicians in the same group practice on the same patient at the same operative session or on the same day for which separate payment may be allowed.

ScopeApplies to procedures subject to Multiple Surgical Reductions (MSR) and NCCI guidelines.

Payment applicationReimbursement is applied by ranking allowed amounts and reducing subsequent procedures per facility-specific tiers.

Modifier sequencing — application guidance

Modifier sequencing ruleApply modifiers that affect payment in the first modifier field, followed by informational modifiers.

PurposeEnsure payment-affecting modifiers are read and applied before informational modifiers when processing claims.