CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

In Lieu Of Services (alternative non-state-plan services)

Defines Neighborhood Health Plan of RI coverage and billing guidance for approved In Lieu Of Services (chiropractic, massage therapy, acupuncture) as substitutes for state plan services across Medicaid (excluding EFP), INTEGRITY, and Commercial lines.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyIn Lieu Of Services (alternative non-state-plan services)

Policy CodePolicy N/A

Change TypeClarified (no material changes)

Effective DateN/A

Next Review DateN/A

Key ActionProviders must submit the Neighborhood In Lieu Of Prior Authorization Request Form and attest that the service is being provided in lieu of the described State Plan service; authorization and medical necessity criteria will be applied.

SourceLink

POLICY UPDATE CHANGES

Document history notes prior updates (including physiotherapy coding table added 2021) but the 01/01/2023 review indicated no content changes.

3Types of In Lieu Of services approved

12Annual rolling visit limit for chiropractic and acupuncture

6Annual rolling visit limit for massage therapy

Medical Necessity & Approval Criteria

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Medical necessity and approval criteria

Services are covered when medically necessary and appropriate as substitutes for State Plan services. Neighborhood may use the following sources to determine medical necessity:

ALL of the following

Service must be effective for treatment and improve the member's quality of health; provider must attest that the service is used in lieu of the described State Plan service via Neighborhood In Lieu Of Prior Authorization Request Form.
Medical necessity determination may reference National Coverage Determinations (NCD), Local Coverage Determinations (LCD), InterQual or other industry-accepted criteria, Rhode Island EOHHS recommendations, and Neighborhood Clinical Medical Policies (CMP).
Provider is responsible for verifying member eligibility, coverage and authorization prior to rendering services.

duplicate

Service must be effective for treatment and improve the member's quality of health; provider must attest that the service is used in lieu of the described State Plan service via Neighborhood In Lieu Of Prior Authorization Request Form.
Medical necessity determination may reference National Coverage Determinations (NCD), Local Coverage Determinations (LCD), InterQual or other industry-accepted criteria, Rhode Island EOHHS recommendations, and Neighborhood Clinical Medical Policies (CMP).
Provider is responsible for verifying member eligibility, coverage and authorization prior to rendering services.

Code Groups and Billing Categories

Acupuncture codes (licensed Acupuncturists)CPTCovered

97810	Acupuncture, 1 or more needles; without electrical stimulation, initial 15 minutes
97811	Acupuncture, each additional 15 minutes; with re-insertion of needle(s) (add-on)
97813	Acupuncture with electrical stimulation, initial 15 minutes
97814	Acupuncture with electrical stimulation, each additional 15 minutes (add-on)

Massage therapy codes (licensed Massage Therapists; also by Chiropractors with Physiotherapy license)CPTCovered

97110	Therapeutic procedure; therapeutic exercises, each 15 minutes
97112	Neuromuscular reeducation, each 15 minutes
97124	Massage, each 15 minutes
97140	Manual therapy techniques, each 15 minutes

Chiropractic manipulation codesCPTCovered

98940	Chiropractic manipulative treatment; spinal, 1-2 regions
98941	Chiropractic manipulative treatment; spinal, 3-4 regions
98942	Chiropractic manipulative treatment; spinal, 5 regions

Chiropractor with Physiotherapy license — additional modality and therapy codesmixedCovered

97010	Hot or cold packs
97012	Traction, mechanical
97014	Electrical stimulation (unattended)
97016	Vasopneumatic devices
97018	Paraffin bath
97022	Whirlpool
97024	Diathermy
97026	Infrared
97028	Ultraviolet
97032	Electrical stimulation (manual), each 15 minutes

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Authorization, Documentation & Billing Rules

Prior Authorization

Prior authorization and attestation

Providers must submit the Neighborhood In Lieu Of Prior Authorization Request Form and attest that the service is being provided in lieu of the described State Plan service. Authorization criteria and determinations of medical necessity will be applied.

Submit the Neighborhood In Lieu Of Prior Authorization Request Form
Attest on the form that the service is being provided in lieu of the described State Plan service

Documentation Required

Medical necessity documentation sources

Providers should supply documentation supporting medical necessity; Neighborhood may reference National Coverage Determinations (NCD), Local Coverage Determinations (LCD), InterQual, Rhode Island EOHHS recommendations, and Neighborhood Clinical Medical Policies (CMP) when adjudicating requests.

National Coverage Determination (NCD)
Local Coverage Determination (LCD)
InterQual (industry accepted criteria)
Rhode Island Executive Office of Health and Human Services (EOHHS) recommendations
Neighborhood Clinical Medical Policies (CMP)

Billing Rule

Claims and coding standards

Providers must submit complete claims within contractually determined timely filing limits and code claims according to CPT, ICD-10-CM and HCPCS Level II coding standards. Billable services are subject to contract terms, claims payment edits and audits.

Timely filing: submit complete claims within contractually determined timely guidelines
Code claims using CPT, ICD-10-CM, and HCPCS Level II coding standards
Claims are subject to contractual edits, payment rules and audit review

Scope & Policy Context

This policy defines Neighborhood Health Plan of Rhode Island coverage and billing guidance for approved In Lieu Of Services — alternative, non‑State‑Plan therapies (specifically chiropractic, massage therapy, and acupuncture) that may be provided as substitutes for State Plan services when medically appropriate and approved by Rhode Island EOHHS. The policy applies to Medicaid (excluding Extended Family Planning), INTEGRITY, and Commercial lines of business and describes the approved services, applicable coding, prior authorization and documentation expectations, and benefit limits.

Services described in this policy are covered when medically necessary and when the provider attests via the Neighborhood In Lieu Of Prior Authorization Request Form that the service is being provided in lieu of the described State Plan service. Neighborhood may rely on National Coverage Determinations, Local Coverage Determinations, InterQual or other industry‑accepted criteria, Rhode Island EOHHS recommendations, and Neighborhood Clinical Medical Policies when adjudicating medical necessity. Providers are responsible for verifying member eligibility, coverage and obtaining authorization prior to rendering services.

Benefit limits stated in the policy include an annual rolling limit of 12 visits per year for chiropractic services, 12 visits per year for acupuncture, and 6 visits per year for massage therapy. Providers must submit claims within contractual timely‑filing limits and code services according to CPT, ICD‑10‑CM and HCPCS Level II standards; billable services remain subject to provider contract terms, claim edits and payment rules.

This document is informational and is not a guarantee of reimbursement. Claim payment is subject to member eligibility, benefit coverage, claims‑processing edits, coding and documentation guidelines, authorization requirements, provider contract terms, and applicable state and federal regulations. The policy history notes an annual review on 01/01/2023 with no content changes.

Policy Update Changes

2023-01-01Annual reviewLatest

Annual policy review conducted on 01/01/2023 with no content changes identified; document history notes prior updates including a 2021 addition of physiotherapy coding.

2021-11-02Policy update

Policy updated to include the physiotherapy coding table.

2021-09-29Annual review

Annual policy review conducted on 09/29/2021 with no content changes noted.

2020-07-16Review

Policy review dated 07/16/2020.

2018-07-01Effective date (Medicaid)

Policy became effective for Medicaid on 07/01/2018.

2018-01-01Effective date (INTEGRITY)

Policy became effective for INTEGRITY on 01/01/2018.