STI Testing Payment Policy — Reimbursement consolidation to CPT 87801
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Governs reimbursement when multiple individual STI nucleic acid test CPT codes are billed the same date of service by the same provider; affects providers submitting claims to Neighborhood Health Plan of Rhode Island across all lines of business.
Neighborhood is implementing a new STI Testing Payment Policy that limits reimbursement when two or more specified individual laboratory CPT codes are submitted on the same date of service.
Providers should continue to submit the individual CPT codes for the specific tests performed for HEDIS and quality measurement.
Reimbursement and Submission Criteria
Reimbursement and submission criteria
Payment will be adjusted when multiple individual STI test codes are billed together; medical necessity and documentation rules still apply.
ALL of the following
ALL of the following
- 87801 — Infectious agent detection by nucleic acid, multiple organisms; amplified probe technique (consolidated reimbursement code).
The system will automatically adjust reimbursement when applicable.
ALL of the following
- Providers must continue to submit the individual CPT code(s) that correspond to the specific test(s) performed to ensure HEDIS and quality measure capture.
ALL of the following
- All services must be medically necessary and meet applicable coverage, coding, and documentation requirements; contact Provider Services with questions.
STI Nucleic Acid Test Codes & Reimbursement Limits
Billing Rule and Provider Instructions
Reimbursement consolidated to CPT 87801 when multiple individual STI test codes billed
When two or more of the individual laboratory CPT codes 87491, 87591, or 87661 are submitted by the same provider for the same member on the same date of service, Neighborhood will limit reimbursement to the established payment rate for CPT 87801 and to one unit regardless of number of units billed. The system will automatically adjust reimbursement when applicable.
Submission and Code Definitions
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