CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Provider Preventable Conditions (PPCs) reimbursement policy

Governs non-payment and billing/reporting requirements for Provider Preventable Conditions (including Hospital Acquired Conditions and Other Provider Preventable Conditions) for Neighborhood Health Plan of Rhode Island across listed lines of business.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyProvider Preventable Conditions (PPCs) reimbursement policy

Policy CodePolicy N/A

Change TypeFormat updatesadministrative reviews (no material clinical changes)

Effective DateJul 1, 2012

Next Review DateN/A

Key ActionVerify eligibility, coverage and authorization criteria prior to rendering services and contact Provider Services at 1-800-963-1001 when needed.

SourceLink

POLICY UPDATE CHANGES

10/01/2022 policy review: Format changes, no content changes.

01/06/2020 policy review: Updated to include all lines of business.

14CMS-designated HAC categories referenced

2012-07-01Effective date

11/28/2023Most recent review

Non-Reimbursement Rules for Provider Preventable Conditions

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.

Services attributable to Hospital Acquired Conditions (HACs) or Other Provider Preventable Conditions (Never Events) are non-reimbursable; members are not liable for copays or deductibles for these non-reimbursable services.

All services provided in the operating room or other healthcare setting when an Other Provider Preventable Condition or HAC occurs are considered related to the HAC and are not reimbursed; such services must be reported as HAC-related on claims.

Follow-up services resulting from a previously reported PPC for the same member are not reimbursed and must be reported as HAC-related services.

Providers who could bill individually for services when an HAC occurs are not eligible for payment; those services must be reposted as HAC-related services.

Present on Admission (POA) indicator reporting is mandatory for all inpatient admission claims; the POA indicator in conjunction with a HAC diagnosis code determines payment adjustments (Y = present; N = not present; U/blank/exempt handled as specified).

Other Provider Preventable Conditions (Never Events) must be coded and reported using the specified diagnosis codes and claim/bill types; examples include Y65.51, Y65.52, Y65.53 and non-covered claims with bill type 0110 where applicable.

A complete, up-to-date list of HAC ICD-10 codes is maintained by CMS and must be referenced for coding and payment determinations.

Providers must submit complete claims within timely filing guidelines and follow AMA CPT, ICD-10-CM, and HCPCS coding standards; documentation supporting billed services and medical necessity must be available to Neighborhood upon request.

Neighborhood reserves the right to request medical records, perform audits, and apply payment edits; this policy is informational and does not guarantee payment.

Coding, POA Reporting, and Examples

PPC coding references and examplesICD-10 | HCPCSCovered

See CMS ICD-10 HAC list	Complete list of corresponding ICD-10 diagnosis codes by Federal fiscal year available on CMS website for HACs
Y65.51	Performance of wrong procedure (operation) on correct patient
Y65.52	Performance of operation (procedure) on patient (wrong?)
Y65.53	Performance of correct operation (procedure) on wrong side/body part
PA	Surgery Wrong Body Part
PB	PB
PC	Surgery Wrong Patient

Non-covered claim billing codemixedNot Covered

0110	Bill type for non-covered claim

Present on Admission (POA) reporting

POA reporting requirementPOA indicator reporting is mandatory for all inpatient admission claims to acute care hospitals or other facilities

POA use for payment determinationThe POA indicator in conjunction with a HAC diagnosis code determines the payment implications of a claim (Y = present; N = not present; U/blank/exempt handled as specified)

POA code meaningsY = Diagnosis present at time of inpatient admission (payment made); N = Diagnosis not present (applicable PPC payment adjustments made); U/blank/exempt = documentation insufficient/clinically undetermined or exempt from POA reporting

Verification, Documentation, and Contact Requirements

Documentation Required

Verification and documentation

Providers must verify member eligibility, coverage, and any prior authorization requirements before rendering services. Neighborhood may determine medical necessity using Local Coverage Determinations (LCD), National Coverage Determinations (NCD), industry-accepted criteria such as InterQual, Rhode Island EOHHS recommendations, and Neighborhood Clinical Medical Policies (CMP).

Verify member eligibility and benefits prior to service.
Confirm whether prior authorization is required via Neighborhood's plan-specific Prior Authorization Reference page.
Check Neighborhood Clinical Medical Policies for coverage and medical necessity criteria.
Neighborhood may request medical records to support billed services and medical necessity; maintain complete documentation per CMS standards.
Commercial members may be responsible for coinsurance, copays, and deductibles — confirm member cost-sharing obligations prior to service.

Key Definitions

Provider Preventable Conditions (PPCs) definition

PPC definitionProvider Preventable Conditions (PPCs) are adverse events or conditions that develop during a hospital stay and include Hospital Acquired Conditions (HACs) and Other Provider Preventable Conditions (Never Events)

Scope of PPCsIncludes CMS-designated HACs and Other Provider Preventable Conditions as defined under 42 CFR 447.266

Payment stanceNeighborhood will not reimburse facilities or professional providers for increased incremental costs of inpatient care or professional services resulting from PPCs

Present on Admission (POA) definition

POA definitionPresent on Admission (POA): Conditions present at the time an order for inpatient admission occurs, or that develop during an outpatient encounter (including emergency department, observation, or outpatient surgery)

Hospital Acquired Condition (HAC) definition

HAC definitionA Hospital Acquired Condition (HAC) is an undesirable condition or complication developed by a patient during a stay in a hospital or medical facility

CMS HAC categoriesCMS has designated fourteen (14) categories of HACs (complete corresponding ICD-10 diagnosis code lists are published on the CMS website)

HAC and POA relationshipHACs are conditions not identified as present on admission (POA) on the UB-04 claim form; POA indicator with HAC diagnosis code determines payment adjustments