CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Temporary expansion of telemedicine and telephone-only services reimbursement

Temporary policy expanding coverage and reimbursement rules for telemedicine and telephone-only medical services for Neighborhood participating providers across Medicaid, Commercial, and INTEGRITY lines of business during the COVID-19 emergency.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyTemporary expansion of telemedicine and telephone-only services reimbursement

Policy CodePolicy N/A

Change TypeOperational additions and waivers

Effective DateMar 18, 2020

Next Review DateN/A

Key ActionPrior authorization requirements will be waived for the telemedicine/telephone-only services outlined in this policy.

SourceLink

POLICY UPDATE CHANGES

Emergency Department and OHIC language regarding patient location were added.

Prior authorization requirements for the telemedicine/telephone-only services outlined in this policy will be waived.

Documentation requirements and member cost-share waiver requirements were updated.

100%reimbursement relative to in-office allowable

90 daysclaim submission timeframe

Commercialplans with cost-share waived

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.

Telemedicine and Telephone Coverage Criteria

Telemedicine/Telephone Coverage Criteria and Rules

Telemedicine/telephone-only services are covered when documentation, clinical appropriateness, and billing rules are met; specific inclusions and exclusions apply.

ALL of the following

Patient must be present/participate at time of service
Service must meet key components/requirements equivalent to face-to-face interaction
Service must be medically necessary and covered under member benefit plan
Service must be within provider's scope of license
A permanent record of the telemedicine/telephone communication must be maintained in the medical record

Inclusions (any of the following provider types may bill):

Primary care physicians
All medical specialists (MD, DO, NP, PA)
Optometrists
Doctors of Podiatric Medicine (DPM)
Chiropractors (DC)
Lactation consultants
Physical, occupational and speech therapists

Exclusions (any of the following are NOT covered):

Services rendered through email, text, fax, or patient portal
Telemedicine that occurs the same day as a face-to-face visit by the same provider for the same condition
Patient communications incidental to E&M services (e.g., test results, education)
Administrative matters (scheduling, registration, reminders, refill requests, ordering studies, history intake by patient)
Encounters conducted by office staff, RNs, LPNs, etc.
Services not clinically appropriate for telemedicine/telephone (e.g., manual manipulation or manual therapy billed via telemedicine)

Billing and operational rules:

Providers must submit complete claims within 90 days of service
Place of Service 02 must be used and modifier CR (Catastrophe/Disaster Related) must be included on claims
Telemedicine is reimbursed as a place of service (not a distinct benefit) and will be reimbursed at 100% of the in-office allowable
Prior authorization requirements for the telemedicine/telephone-only services outlined in this policy are waived
Documentation requirements for telemedicine/telephone-only services are the same as face-to-face encounters
Neighborhood may audit medical and administrative records to verify services, medical necessity, and coding appropriateness

ALL of the following

Neighborhood reserves the right to audit medical records and administrative records related to adherence to this policy to verify nature of services, medical necessity, clinical appropriateness for telemedicine/telephone, and appropriateness of E/M coding

Claim Coding and Reimbursement

Reimbursement rate — percent of in-office allowable

Reimbursement rateNeighborhood will reimburse telemedicine/telephone encounters at 100% of the in-office allowable.

Audit rightsNeighborhood reserves the right to audit medical and administrative records to verify services, medical necessity, and coding appropriateness.

Documentation parityDocumentation requirements for telemedicine/telephone-only services are the same as those required for any face-to-face encounter.

Provider Requirements and Actions

Prior Authorization

Prior authorization waiver for telemedicine/telephone services

Prior authorization requirements for the telemedicine/telephone-only services described in this policy are waived for the policy timeframe.

Definitions

Clinically appropriate, medically necessary covered health services provided remotely via telemedicine or telephone during the COVID-19 emergency

DefinitionClinically appropriate, medically necessary covered health services provided remotely via telemedicine or telephone during the COVID-19 emergency.

Provider and scopeServices must be within the provider's scope of license and billed by Neighborhood participating providers.

Patient participationThe patient must be present/participate at the time of service; a permanent record of the communication must be maintained in the medical record.

Clinical equivalenceServices must meet the key components/requirements equivalent to the same service when rendered face-to-face and must be medically necessary and covered under the member's benefit plan.