Neighborhood Health Plan RI non-covered codes | OpenPayer

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Neighborhood Health Plan RI non-covered codes | OpenPayer

Code Examples and Code Tables

Not Covered HCPCS/CPT/OthermixedNot Covered

Q4273	Non-covered code Q4273
Q4274	Non-covered code Q4274
Q4275	Non-covered code Q4275

Not Covered HCPCS/CPT/OthermixedNot Covered

Q4276	Non-covered code Q4276
Q4277	Non-covered code Q4277
Q4278	Non-covered code Q4278

Not Covered HCPCS/CPT/OthermixedNot Covered

Q4280	Non-covered code Q4280
Q4281	Non-covered code Q4281
Q4282	Non-covered code Q4282

Not Covered HCPCS/CPT/OthermixedNot Covered

Q4283	Non-covered code Q4283
Q4284	Non-covered code Q4284
Q9001	Non-covered code Q9001

Not Covered HCPCS/CPT/OthermixedNot Covered

Q9002	Non-covered code Q9002
Q9003	Non-covered code Q9003
Q9004	Non-covered code Q9004

Not Covered HCPCS/CPT/OthermixedNot Covered

Q9991	Non-covered code Q9991
Q9992	Non-covered code Q9992
R0070	Non-covered code R0070

Not Covered HCPCS/CPT/OthermixedNot Covered

R0075	Non-covered code R0075
R0076	Non-covered code R0076
S0090	Non-covered code S0090

Not Covered HCPCS/CPT/OthermixedNot Covered

S0126	Non-covered code S0126
S0128	Non-covered code S0128
S0207	Non-covered code S0207

Not Covered HCPCS/CPT/OthermixedNot Covered

S0208	Non-covered code S0208
S0209	Non-covered code S0209
S0215	Non-covered code S0215

Not Covered HCPCS/CPT/OthermixedNot Covered

S0257	Non-covered code S0257
S0285	Non-covered code S0285
S0311	Non-covered code S0311

Not Covered HCPCS/CPT/OthermixedNot Covered

S0353	Non-covered code S0353
S0354	Non-covered code S0354
S0500	Non-covered code S0500

Not Covered HCPCS/CPT/OthermixedNot Covered

S0504	Non-covered code S0504
S0506	Non-covered code S0506
S0508	Non-covered code S0508

Not Covered HCPCS/CPT/OthermixedNot Covered

S0510	Non-covered code S0510
S0512	Non-covered code S0512
S0514	Non-covered code S0514

Not Covered HCPCS/CPT/OthermixedNot Covered

S0515	Non-covered code S0515
S0516	Non-covered code S0516
S0518	Non-covered code S0518

Not Covered HCPCS/CPT/OthermixedNot Covered

S0581	Non-covered code S0581
S0590	Non-covered code S0590
S0592	Non-covered code S0592

Not Covered HCPCS/CPT/OthermixedNot Covered

S0595	Non-covered code S0595
S0596	Non-covered code S0596
S0800	Non-covered code S0800

Not Covered HCPCS/CPT/OthermixedNot Covered

S0810	Non-covered code S0810
S1015	Non-covered code S1015
S1034	Non-covered code S1034

Not Covered HCPCS/CPT/OthermixedNot Covered

S1035	Non-covered code S1035
S1036	Non-covered code S1036
S1037	Non-covered code S1037

Not Covered HCPCS/CPT/OthermixedNot Covered

S2102	Non-covered code S2102
S2103	Non-covered code S2103
S2117	Non-covered code S2117

Not Covered HCPCS/CPT/OthermixedNot Covered

S2230	Non-covered code S2230
S2900	Non-covered code S2900
S3655	Non-covered code S3655

Not Covered HCPCS/CPT/OthermixedNot Covered

S4027	Non-covered code S4027
S4988	Non-covered code S4988
S5100	Non-covered code S5100

Not Covered HCPCS/CPT/OthermixedNot Covered

S5105	Non-covered code S5105
S5108	Non-covered code S5108
S5109	Non-covered code S5109

Not Covered HCPCS/CPT/OthermixedNot Covered

S5110	Non-covered code S5110
S5111	Non-covered code S5111
S5115	Non-covered code S5115

Not Covered HCPCS/CPT/OthermixedNot Covered

S5116	Non-covered code S5116
S5126	Non-covered code S5126
S5135	Non-covered code S5135

Not Covered HCPCS/CPT/OthermixedNot Covered

S5136	Non-covered code S5136
S5160	Non-covered code S5160
S5161	Non-covered code S5161

Not Covered HCPCS/CPT/OthermixedNot Covered

S5162	Non-covered code S5162
S5165	Non-covered code S5165
S5180	Non-covered code S5180

Not Covered HCPCS/CPT/OthermixedNot Covered

S5181	Non-covered code S5181
S5185	Non-covered code S5185
S5190	Non-covered code S5190

Not Covered Vaccine CodesmixedNot Covered

90619	Non-covered vaccine code 90619 (example)
90624	Non-covered vaccine code 90624 (example)

Partial list - Non-Covered ProceduresmixedNot Covered

99493	Non-covered code 99493
99494	Non-covered code 99494

Partial list - Non-Covered ProceduresmixedNot Covered

99495	Non-covered code 99495
99496	Non-covered code 99496

Sample non-covered procedure codesmixedNot Covered

99500	Non-covered code 99500
99503	Non-covered code 99503
99504	Non-covered code 99504
99505	Non-covered code 99505

Sample non-covered T-codes rangemixedNot Covered

0489T	Non-covered code 0489T
0490T	Non-covered code 0490T

Sample non-covered T-codes rangemixedNot Covered

0823T	Non-covered code 0823T
0824T	Non-covered code 0824T

Additional examples — non-coveredmixedNot Covered

0838T	Non-covered code 0838T
0839T	Non-covered code 0839T
0840T	Non-covered code 0840T

Examples of non-covered codesmixedNot Covered

C9796	Non-covered code C9796
D0210	Non-covered code D0210
D7140	Non-covered code D7140

Example non-covered G-codesmixedNot Covered

G0473	Non-covered code G0473
G0493	Non-covered code G0493
G0494	Non-covered code G0494

Large sample non-covered codes (partial)mixedNot Covered

G9625	Non-covered code G9625
G9626	Non-covered code G9626
G9627	Non-covered code G9627
G9628	Non-covered code G9628
G9629	Non-covered code G9629
G9630	Non-covered code G9630

Extensive Q-code non-covered list (partial)mixedNot Covered

Q4236	Non-covered code Q4236
Q4237	Non-covered code Q4237
Q4238	Non-covered code Q4238
Q4239	Non-covered code Q4239
Q4240	Non-covered code Q4240
Q4241	Non-covered code Q4241
Q4242	Non-covered code Q4242
Q4243	Non-covered code Q4243
Q4244	Non-covered code Q4244
Q4245	Non-covered code Q4245

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Billing Guidance and Provider Notices

Billing Rule

Non‑Covered Code Legend

List indicates non‑covered (X) versus covered (blank) for specific procedure codes across the Medicaid, Commercial, and INTEGRITY product lines.

Billing Rule

Non‑Covered Services — code status listing

This section lists CPT/HCPCS and other procedure codes with coverage status indicators; 'X' denotes Non‑Covered and a blank denotes Covered for each product column (Medicaid, Commercial, INTEGRITY).

Billing Rule

Non‑Covered Codes (partial list)

The table includes CPT/HCPCS and temporary/proprietary codes (e.g., 0146U–0514T) with per‑product flags—codes marked 'X' in a product column are non‑covered for that product; a blank indicates coverage.

Billing Rule

Non‑Covered Services — T‑codes list

This portion enumerates T‑codes; when a code shows 'X' under Medicaid, Commercial, or INTEGRITY it is designated non‑covered for that product.

Billing Rule

Non‑Covered Codes — provider billing guidance

Procedure and supply codes marked 'X' for a given product are non‑covered; providers should not expect payment for services billed with those codes where the product column is marked 'X'.

Billing Rule

Non‑Covered Codes listing — format

Codes in the listing are shown with per‑product indicators: 'X' (Non‑Covered) or blank (Covered). Confirm the appropriate product column when billing to determine coverage.

Billing Rule

Non‑Covered Services — G‑code flags

HCPCS G‑codes in the table include per‑program non‑coverage flags; any G‑code with 'X' under Medicaid or Commercial is non‑covered for that program.

Billing Rule

Non‑Covered Services (codes list)

The code lists include many HCPCS/CPT/Type II codes flagged 'X' for Medicaid and/or Commercial; a code marked 'X' in a payer column is not covered for that payer.

Billing Rule

Non‑Covered Services — code list

Codes marked with an 'X' in the Medicaid and/or Commercial columns are considered non‑covered services; a blank indicates the service is covered for that product.

Legend and Indicator Definitions

inv-33: Coverage legend — X = Non-Covered; blank = Covered

Coverage legendX = Non-Covered; blank = Covered

Effective year/2024 (legend shown throughout document)

Applies toMedicaid, Commercial, INTEGRITY product columns

inv-34: Coverage status legend — X, 1 = Non-Covered. Blank, 1 = Covered

Coverage status legendX, 1 = Non-Covered. Blank, 1 = Covered

ContextShown at the top of code listing sections to explain table flags

Applies to codesIndicates per-code status in Medicaid/Commercial/INTEGRITY columns

inv-35: coverage flag legend — X, 1 = Non-Covered. Blank, 1 = Covered

Flag legendX, 1 = Non-Covered. Blank, 1 = Covered

LocationRepeated between code table sections (e.g., U-code listings)

Provider noteCheck the specific product column for X or blank when billing

inv-36: Non‑covered marker — X = Non‑Covered; blank = Covered

Non‑covered markerX = Non‑Covered; blank = Covered

Example codesMultiple T-codes in section show X for Medicaid/Commercial/INTEGRITY

Billing consequenceDo not expect coverage for codes marked X for the member's product

inv-37: Coverage marker legend — X, 1 = Non-Covered. Blank, 1 = Covered

Coverage marker legendX, 1 = Non-Covered. Blank, 1 = Covered

Applies to listUsed across extended T-code ranges in the document

Operational noteWhen present, X applies specifically to the product column shown

inv-38: non-coverage marker — X = Non-Covered; Blank = Covered

Non-coverage markerX = Non-Covered; Blank = Covered

Where seenAppears in dental and other code groups with INTEGRITY flags

VerifyConfirm member product column before billing

inv-39: X = Non-Covered — 'X' indicates the service/code is non-covered for that product column; blank indicates covered.

X = Non-Covered'X' indicates the service/code is non-covered for that product column; blank indicates covered.

ExampleG-codes in the section show X for Medicaid/Commercial depending on code

ActionIf X appears under a member's product, treat the code as non-covered

inv-40: Non-Covered indicator — X or 1 indicates the code is non-covered; blank indicates covered

Non-Covered indicatorX or 1 indicates the code is non-covered; blank indicates covered

Usage guidanceCheck the specific product column in the code table to determine coverage

DocumentationRepeated at the head/footer of multiple code list pages

inv-41: Non-Covered indicator — 'X' = Non-Covered; blank = Covered

Non-Covered indicator'X' = Non-Covered; blank = Covered

ScopeApplies across Q-code and other code blocks in the listing

Provider instructionDo not bill Neighborhood Health Plan for codes marked X for the member's product