CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Non-Covered CPT/HCPCS Codes List

Lists procedure and vaccine CPT/HCPCS codes designated as non-covered across Medicaid, Commercial and INTEGRITY product lines for the provided portion of the policy.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyNon-Covered CPT/HCPCS Codes List

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionDo not submit claims using codes marked with 'X' for the product lines indicated; use the listing to validate billing and avoid non-covered code submissions.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

20+document chunks in this extract containing non-covered codes

~320+codes listed as non-covered in this segment

3coverage columns shown

yesincludes temporary/unique codes

Non-covered Codes by Product Line

Non-covered codes (partial)

The document enumerates CPT/HCPCS codes designated as non-covered for specific payer types.

Codes listed as non-covered for one or more payer types in the provided chunks; examples include 00938 (Commercial = X, INTEGRITY = X), 15769 (Medicaid = X, Commercial = X, INTEGRITY = X), 80355 (Medicaid = X, Commercial = X, INTEGRITY = X).

Non-Covered Codes List

The document section enumerates codes considered non-covered by product line; no service‑specific clinical criteria are provided — only code‑level non‑coverage markers.

Sample codes listed as non-covered in this excerpt: 89356 (Medicaid = X, Commercial = X, INTEGRITY = X), 0221U/0221T (Medicaid/Commercial/INTEGRITY flagged where shown). Providers should note some entries show blanks for particular product columns in the extract.

Non-Covered Codes

Enumerated procedure codes in this range are designated non-covered.

Selected procedure codes marked non-covered across Medicaid, Commercial, and INTEGRITY in this excerpt include 0212T–0559T (examples: 0212T, 0301U, 0434U, 0559T). Coverage flags (X) are shown per product line next to each code.

Non-covered codes list

This document segment enumerates codes that are designated non-covered by plan type.

Temporary CPT T-codes and related entries shown as non-covered in this segment include examples such as 0519T, 0520T, 0536T, 0541T and modifier/F codes such as 1200F and 2023F (coverage flags shown per payer).

Non-covered codes list (partial)

This section enumerates codes designated as non-covered by product line. Each code line shows coverage flags for Medicaid, Commercial, and INTEGRITY.

Examples in this partial list include multiple T-codes (e.g., 0871T, 0888T, 0900T) and F/modifier entries (e.g., 1200F, 2023F) with per‑product non‑coverage markers (X) or blanks where not marked in the extract.

Per-code coverage indicators (non-covered)

Each listed HCPCS/CPT/G code is annotated with coverage indicators by line of business; codes marked with 'X' are non-covered.

Sample HCPCS/G-code entries shown as non-covered include E0246 (Commercial = X), G0030 (Medicaid = X; Commercial = X; INTEGRITY = X), and multiple G-series codes (G0260–G0314) with per‑line X markers indicating non‑coverage where present.

Non-Covered Codes

Enumerated codes are shown with payer‑specific non‑coverage indicators in this excerpt.

Examples include G2086, G9999, K1001 and H0051 marked X for Medicaid, Commercial and INTEGRITY in the excerpt; multiple J‑codes (e.g., J0270) are shown with Medicaid = X and Commercial/INTEGRITY blank in this extract.

Non-Covered Codes

Codes listed below are designated non-covered for the product columns shown; coverage varies by code and product line.

This segment lists numerous HCPCS/CPT codes marked non‑covered for one or more product lines (examples: G9999, H0051, H2038 marked X across lines; J0270, K1001, L0984 show mixed markers or blanks).

Non-covered codes list

Codes and their non‑coverage status by product line (Medicaid, Commercial, INTEGRITY) shown in this extract include the following examples.

S5108 (Medicaid = X, Commercial = X, INTEGRITY = X); S5135 (Medicaid = ., Commercial = X, INTEGRITY = .); T1004 (Medicaid = X, Commercial = X, INTEGRITY = X); V5271 (Medicaid = X, Commercial = X, INTEGRITY = X). Many additional codes in this section are similarly annotated; blanks or '.' indicate the code is not marked non‑covered for that product in the extract.

Code Tables and Legend

Examples of non-covered CPT/HCPCS codesCPTNot Covered

00938	Listed as non-covered for Commercial and INTEGRITY in this extract
11200	Listed as non-covered for Commercial in this extract
15769	Listed as non-covered for Medicaid, Commercial, and INTEGRITY in this extract

Non-covered CPT/HCPCS and temporary codes (partial list)mixedNot Covered

89356	Procedure code listed as non-covered (example entry)
0221U	Temporary/unique code listed as non-covered (example entry)

Non-covered procedure codes (sample)CPT | HCPCSNot Covered

0212T	Non-covered (Medicaid = X, Commercial = X, INTEGRITY = X)
0301U	Non-covered (Medicaid = X, Commercial = X, INTEGRITY = X)
0434U	Non-covered (Medicaid = X, Commercial = X, INTEGRITY = X)
0559T	Listed as Non-Covered; commercial/INTEGRITY entry truncated in this excerpt

Selected non-covered codes from sectionmixedNot Covered

0519T	Temporary CPT code listed as non-covered
0520T	Temporary CPT code listed as non-covered
0900T	Temporary CPT code listed as non-covered
1200F	Modifier/HCPCS F code listed (Commercial = X)
2023F	Modifier/HCPCS F code listed (Medicaid = X)

Non-covered CPT/HCPCS codes (sample entries)mixedNot Covered

0871T	Procedure code marked non-covered for Medicaid, Commercial, INTEGRITY in this excerpt
0888T	Procedure code shown as non-covered for Commercial and INTEGRITY in this excerpt
1200F	Modifier/code with differing coverage: Commercial = X; Medicaid = . in this excerpt

Examples of non-covered HCPCS/CPT codesmixedNot Covered

E0246	Listed as non-covered for Commercial in this extract
G0008	Listed as non-covered for Medicaid in this extract
G0102	Listed as non-covered for Commercial in this extract

Examples of non-covered codes in excerptmixedNot Covered

G2086	Listed as non-covered (Medicaid = X; Commercial = X; INTEGRITY = X)
G9999	Listed as non-covered (Medicaid = X; Commercial = X; INTEGRITY = X)
J0270	Listed as non-covered for Medicaid = X; Commercial and INTEGRITY shown as blank or not covered in excerpt
K1001	Listed as non-covered (Medicaid = X; Commercial = X; INTEGRITY = X)
H0051	Listed as non-covered (Medicaid = X; Commercial = X; INTEGRITY = X)

Examples of non-covered codes in this segmentmixedNot Covered

G9999	Listed as non-covered (Medicaid, Commercial, INTEGRITY = X)
H0051	Listed as non-covered (Medicaid, Commercial, INTEGRITY = X)
H2038	Listed as non-covered (Medicaid, Commercial, INTEGRITY = X)
J0270	Listed as non-covered for Medicaid; Commercial and INTEGRITY blank
K1001	Listed as non-covered (Medicaid, Commercial, INTEGRITY = X)
L0984	Listed as non-covered for Medicaid; Commercial and INTEGRITY blank
M0075	Listed as non-covered for Medicaid; Commercial and INTEGRITY blank
P2028	Listed as non-covered (Medicaid, Commercial, INTEGRITY = X)
Q2034	Listed as non-covered for Commercial and INTEGRITY; Medicaid blank
Q4112	Listed as non-covered (Medicaid, Commercial, INTEGRITY = X)

Example non-covered codes extractedmixedNot Covered

S5108	Listed as non-covered for Medicaid, Commercial, INTEGRITY (marked X in all)
S5109	Listed as non-covered for Medicaid, Commercial, INTEGRITY
S5110	Listed as non-covered for Medicaid, Commercial, INTEGRITY
S5135	Commercial = X; Medicaid and INTEGRITY blank
T1004	Medicaid = X, Commercial = X, INTEGRITY = X
T2048	Medicaid = X, Commercial = X, INTEGRITY = X
V5271	Medicaid = X, Commercial = X, INTEGRITY = X
V5298	Medicaid = X, Commercial = X, INTEGRITY = X

coverage-marker-legend

LegendCodes marked 'X' indicate non-covered for that product; blank or '.' indicates not marked non-covered in the listing

Applies toMedicaid, Commercial, INTEGRITY payer columns as shown in the code lists

UseReference this legend when validating billing to avoid submitting codes marked as non-covered

Source contextExtracted from the policy's coverage-marker legend within the non-covered services list

Billing and Submission Guidance

Billing Rule

Non-Covered Codes — summary

The following CPT/HCPCS/temporary/proprietary codes are designated as non-covered by Neighborhood Health Plan of Rhode Island for the product lines shown. Providers should not bill these codes for the corresponding product lines; submission may result in claim denial. This list is a representative (partial) excerpt — always verify current coverage prior to submitting claims.

Sample non-covered entries (partial): 00938 (Commercial, INTEGRITY), 11200 (Commercial), 11201 (Commercial), 15769 (Medicaid, Commercial, INTEGRITY), 15773–15776 (various product line flags), 15780–15793 (various flags), 15824–15828 (Medicaid/Commercial/INTEGRITY).
Temporary/proprietary and miscellaneous non-covered codes (partial): 0001U, 0002M, 0002U, 0003M, 0003U, 0004M, 0005U, 0006M, 0007M, 0007U, etc. — many 'U' and 'M' modifier codes are flagged as non-covered across product lines.
Vaccine/immunization and related codes (partial): 89356, 89398, 90476–90477, 90581, 90585–90587, 90619, 90625–90627, 90630, 90634, 90644, 90648–90651 (various flags).
Maternal/infant and home-visit codes (partial): 99506–99511, 99605–99607 (Medicaid/Commercial/INTEGRITY flagged).
Many CPT temporary (T) series codes are non-covered (partial): 0212T–0220T and U variants, 0519T–0536T, 0871T–0888T, 0519T etc.
Device, supply, drug, and miscellaneous HCPCS/J/K codes (partial): E0246–E0637 (various flags), G2086–G2107 (various G-codes flagged), G9999, H0051, H2038, J0270, J0275, J0565, J1428, J1627, J2787, J3304, J3355, J7345, J9285 (many Medicaid-only non-covered entries), K1001–K1006, S51xx series (many S51xx non-covered).
Billing guidance: 'X' indicates the code is not covered for that product line. A blank or '.' indicates no non-coverage flag shown in this excerpt. Do not rely on this partial listing as sole source of truth — check payer systems for up-to-date adjudication rules and prior authorization requirements.

Denial Risk

Provider Action — Billing Guidance / Denial Risk

Provider action: Validate billing before submission. This section contains partial lists and billing guidance consolidated from the plan source. Use the payer's claim editing tools or provider portal to confirm current non-coverage and prior authorization requirements. Submitting non-covered codes may result in denial without appeal if services are excluded.

Non-covered billing guidance: 'X' in the source indicates not covered for that product line. A blank or '.' in the source excerpt indicates the code was not marked as non-covered in that excerpt — do not assume coverage without verification.
When a code is non-covered for a product line, do not submit it for payment under that product line. If a service is believed to be medically necessary, follow plan processes for prior authorization or clinical review before billing.
Temporary and proprietary codes (U/M modifiers and T-codes) shown as non-covered are frequently excluded; verify alternative covered codes or claim guidance.

Legend and Coverage Markers

coverage marker

Marker meaning'X' appears to denote non-covered for the payer column shown; '.' appears where the code may not be marked non-covered for that payer in this extract

Columns shownEach code row includes payer-specific markers (Medicaid, Commercial, INTEGRITY)

Action for providersDo not submit claims expecting coverage for codes marked with 'X' for the relevant payer column

X (non-covered marker)

DefinitionX marker indicates the code is non-covered for that product line in this listing

Example89356, Medicaid = X. 89356, Commercial = X. 89356, INTEGRITY = X.

ImplicationCodes with X should be treated as not payable under the listed product line

X (non-covered flag)

Flag meaningX indicates the code is non-covered under that benefit type

Example range0212T, Medicaid = X. 0212T, Commercial = X. 0212T, INTEGRITY = X.

Review noteSome entries may show blanks or dots for certain payer columns in the full list

Coverage marker

Coverage marker conventionX indicates the code is non-covered for the specified plan type; '.' indicates no entry/blank in that column

Example0519T, Medicaid = X. 0519T, Commercial = X. 0519T, INTEGRITY = X.

Operational impactBilling systems should map 'X' to non-covered and prevent automatic payment for that payer line

'X' coverage marker

Marker meaningX indicates the code is non-covered for the specified product line within this list

Example0871T, Medicaid = X. 0871T, Commercial = X. 0871T, INTEGRITY = X.

Blank/dot conventionA blank or dot in the payer column indicates the code is not marked as non-covered for that product line in this excerpt

Non-covered flag

Non-covered flag'X' denotes the code is non-covered for that specific line of business (Medicaid, Commercial, INTEGRITY)

ExamplesE0246, Commercial = X (Commercial non-covered); J0270, Medicaid = X (Medicaid non-covered)

Provider actionAvoid billing covered benefit for codes marked with X for the applicable LOB; verify payer-specific guidance for blanks

DesignationX indicates the code is designated non-covered for that payer line in this list

ExamplesG2086, Medicaid = X; G2086, Commercial = X; G2086, INTEGRITY = X

ScopeApplies across G‑codes, J‑codes, K‑codes, H‑codes and other code types shown in the non-covered list

X (non-coverage marker)

Non-coverage indicatorX indicates the code is non-covered for that product line; a blank or dot indicates not marked in this segment

ExampleG9999, Medicaid = X. G9999, Commercial = X. G9999, INTEGRITY = X. J0270, Commercial = . (blank)

NoteCoverage may vary by code and product line; consult the list for payer-specific markers

Coverage marker

Coverage conventionX = code designated as non-covered for that product line as listed

ExamplesS5108, Medicaid = X; S5108, Commercial = X; S5108, INTEGRITY = X

Billing useUse this marker to prevent submission of claims as covered when 'X' is present for the applicable product line

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyNon-Covered CPT/HCPCS Codes List

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionDo not submit claims using codes marked with 'X' for the product lines indicated; use the listing to validate billing and avoid non-covered code submissions.

SourceLink

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