CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Assisted Living services reimbursement

Governs coverage and per-diem reimbursement requirements for Assisted Living services for Neighborhood Health Plan of Rhode Island members on the INTEGRITY (Medicaid) product. Applies to participating and nonparticipating providers delivering assisted living services in residential community care facilities.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyAssisted Living services reimbursement

Policy CodePolicy N/A

Change TypeRevised

Effective DateN/A

Next Review DateN/A

Key ActionVerify member eligibility, coverage and prior authorization before rendering assisted living services.

SourceLink

POLICY UPDATE CHANGES

Updated coverage exclusions to include correct level of care tier.

per diemReimbursement basis for Assisted Living services

Tier A/B/CRate tiers

T2031/T2031-UB/T2031-UCBilling codes

30 daysRecord completion timeframe

monthly shareMember cost responsibility

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Assisted Living Coverage Criteria

Assisted Living coverage criteria

Assisted Living services are covered on a per‑diem basis when medically necessary and documented in accordance with state regulations and Neighborhood requirements. Coverage is tiered by level of ADL support and hours of service.

Services must be medically necessary to qualify for reimbursement; Neighborhood may reference NCD, LCD, InterQual, RI EOHHS guidance, and Clinical Medical Policies to determine medical necessity. Providers are responsible for verifying eligibility, coverage and authorization criteria prior to rendering services.

See plan Prior Authorization Reference page and Clinical Medical Policies for details.

Reimbursement is on a per diem basis; rates are inclusive of all services as specified by the provider contract.

Tier criteria

Tier A: daily assistance with at least two (2) ADLs AND at least one (1) hour of personal care per day.
Use HCPCS code T2031 for Tier A.
Tier B: extensive assistance with a minimum of two (2) ADLs OR seven (7) or more hours per week of any combination of personal care, limited health care services, and care coordination (including behavioral health, memory care, or complex medication management).
Use HCPCS code T2031-UB for Tier B.
Tier C: extensive assistance with a minimum of three (3) ADLs AND sixteen (16) or more hours per week of any combination of personal care, limited health care services, and care coordination (including behavioral health, memory care, or complex medication management).
Use HCPCS code T2031-UC for Tier C.

Activities of Daily Living (ADLs) are defined as Bathing, Dressing, Eating, Mobility, Toileting, and Transferring with the detailed definitions provided in policy.

Documentation requirements: a treatment record must be created for each member and include member identification, physician's order, diagnosis, initial admission assessment, and an Individual Service Plan (ISP) written within seven (7) days after move‑in by a registered nurse or certified assisted living administrator. The ISP must document services, frequency/duration, responsible party, and signature/date of the responsible clinician. Records must include ISP nurse review as required by state regulations, regular member assessments and ISP reviews at least every 12 months or as condition changes, and re‑admission assessment if applicable.

All records must be accurate, legible, and signed no later than 30 days from date of service. Neighborhood may request records at any time to support billed services and medical necessity.

Claim submission and coding: claims may be billed with a date span if services were provided consecutively on each date within the span and within the same month; breaks require a new claim line. Use HCPCS codes T2031 (Tier A), T2031-UB (Tier B), and T2031-UC (Tier C). Inclusion of a code does not guarantee coverage or reimbursement.

Exclusions and denial risk: facility room and board and services duplicative of other covered programs (e.g., Adult Day Health) are excluded. Neighborhood may deny claims if an incorrect level‑of‑care tier is submitted or if the submitted tier does not match member approval by RI EOHHS.

Member cost sharing: INTEGRITY (Medicaid) members have a monthly patient share as determined by RI EOHHS, applied on the first date of service and deducted at payment adjudication.

Billing Codes and Tier Definitions

Assisted Living tier codesHCPCSCovered

T2031	Assisted living, Tier A Facility; Beneficiary A or B Member
T2031-UB	Assisted living, Tier B Facility; Tier B Member
T2031-UC	Assisted living, Tier C Facility; Tier C Member

Tier definitions (ADLs and hours)

Tier ADaily assistance with at least 2 ADLs AND at least 1 hour of personal care per day

Tier BExtensive assistance with a minimum of 2 ADLs OR 7 or more hours per week of any combination of personal care, limited health care services, and care coordination (including behavioral health/memory care or complex medication management)

Tier CExtensive assistance with a minimum of 3 ADLs AND 16 or more hours per week of any combination of personal care, limited health care services, and care coordination (including behavioral health/memory care or complex medication management)

Provider Responsibilities, Billing, and Documentation

Prior Authorization

Verify eligibility and prior authorization

It is the provider's responsibility to verify eligibility, coverage, and authorization criteria prior to rendering services. Providers should confirm member eligibility and any required prior authorization with Neighborhood before delivering services.

Denial Risk

Denial risk for incorrect tier

Neighborhood reserves the right to deny claims if the incorrect level-of-care tier is submitted or does not match what the member is approved for by RI EOHHS.

Documentation Required

Key Terms and Tier Details

Activities of Daily Living (ADLs)

BathingDirect care or constant supervision and cueing during a shower, bath, or sponge bath to maintain adequate hygiene

DressingDirect care or constant supervision and cueing during dressing/undressing and assistance with prostheses, braces, or assisted devices

EatingDirect care, supervision, or physical assistance for part or all of meals to consume food/drink using routine or adapted utensils, including ability to cut, chew, and swallow

MobilityAssistance when member must be steadied, assisted, or guided in ambulation, or is unable to self-propel a wheelchair

ToiletingAssistance for incontinence or catheter/colostomy care, including transferring on/off the toilet, self-cleansing, and changing pads/briefs

TransferringAssisting or lifting the member between surfaces (e.g., bed to chair) and repositioning for pressure relief or tolerance

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyAssisted Living services reimbursement

Policy CodePolicy N/A

Change TypeRevised

Effective DateN/A

Next Review DateN/A

Key ActionVerify member eligibility, coverage and prior authorization before rendering assisted living services.

SourceLink

On This Page

Documentation requests

Neighborhood may request medical records for any billed service at any time. Documentation must support the service(s) billed and demonstrate medical necessity. Records must be kept in accordance with state and federal regulations and follow CMS standards for proper documentation. Once established, any additions, deletions, or edits to the record must comply with Chapter 3 of the CMS Medicare Program Integrity Manual. Electronic health records must meet state and federal privacy guidelines.

Treatment record must include: Member identification (Neighborhood ID, name); Physician's order supporting need for skilled services; Member diagnosis; Initial admission assessment; Individual Service Plan (ISP) written by a registered nurse or certified assisted living administrator within 7 days of move-in, including services/interventions, frequency/duration, responsible party, date and signature; ISP nurse review and regular member assessments per state regulations; ISP review at least every 12 months; Re-admission assessment if applicable.
Records must be accurate, legible, signed, and completed no later than 30 days from date of service.

Billing Rule

Claim submission rules

Claims may be billed with a date span only when services were provided consecutively on each date within the span. Any break in service within a date span must be billed on a new claim line. Dates of service on a single claim span must be within the same month. Providers must submit complete claims within contractually determined timely filing guidelines. Coding must conform to CPT, ICD-10-CM, and HCPCS standards.

Date span billing allowed when services were consecutive on each date within the span.
Breaks in service require a new claim line.
Dates of service must be within the same month.
Submit claims within timely filing deadlines per contract.
Use CPT, ICD-10-CM, and HCPCS coding standards.

Tier levels — ADL assistance and minimum personal care hours

Tier A — ADL assistanceDaily assistance with at least 2 ADLs

Tier A — Minimum hoursAt least 1 hour of personal care per day

Tier B — ADL assistanceExtensive assistance with a minimum of 2 ADLs

Tier B — Minimum hours7 or more hours per week of combined services (personal care, limited health care, care coordination)

Tier C — ADL assistanceExtensive assistance with a minimum of 3 ADLs

Tier C — Minimum hours16 or more hours per week of combined services (personal care, limited health care, care coordination)