CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

In Lieu of Services (alternative non-pharmacologic therapies)

Defines Neighborhood Health Plan of RI's policy for providing certain alternative services (chiropractic, acupuncture, massage) as substitutes for state plan services for eligible members; applies to Medicaid (excluding EFP) and INTEGRITY lines of business.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyIn Lieu of Services (alternative non-pharmacologic therapies)

Policy CodePolicy N/A

Change TypeMaterial updates: Medicaid chiropractic removaladded acupuncture limitations

Effective Date

Next Review Date

Key ActionUse the Neighborhood In Lieu Of Prior Authorization Request Form to attest that the service is being used 'in lieu of' the described State Plan Service and verify eligibility, coverage and authorization prior to rendering services.

SourceLink

POLICY UPDATE CHANGES

Removed chiropractic services for Medicaid effective 7/1/24.

Added exclusion/limitations for acupuncture.

Updated Prerequisites to reference Commercial acupuncture payment policy for commercial coverage.

12 visitsChiropractic annual limit (INTEGRITY)

12 visitsAcupuncture annual limit

6 visitsMassage therapy annual limit

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In Lieu of Services Coverage Criteria

In Lieu of Services coverage criteria

Covered services and prerequisites for coverage.

All services must be medically necessary to qualify for reimbursement.

The requesting provider must attest that the service is being used 'in lieu of' the described State Plan Service using the Neighborhood In Lieu Of Prior Authorization Request Form; provider must verify eligibility, coverage and authorization prior to rendering services.

See Neighborhood In Lieu Of Prior Authorization Request Form and contact Provider Services at 1-800-963-1001 for details.

Neighborhood may use NCD, LCD, InterQual, EOHHS recommendations, and Neighborhood Clinical Medical Policies to determine medical necessity.

Covered in-lieu services (when criteria above are met)

Chiropractic services — covered as an in‑lieu option for INTEGRITY only (removed for Medicaid effective 7/1/24).
Acupuncture services — covered as an in‑lieu option for chronic pain.
Massage therapy — covered as an in‑lieu option for chronic pain.

Benefit limitations (apply when service is covered)

Chiropractic services: limited to 12 visits per rolling year; limited to one unit of the listed chiropractic codes per day.
Acupuncture services: limited to 12 visits per rolling year; acupuncture assistants will not be separately reimbursed; acupuncture is limited to the office setting (not covered in home, nursing, residential, domiciliary, or custodial facilities).
Massage therapy: limited to 6 visits per rolling year.
Exclusion: any service not specifically listed as covered is excluded.

Providers should refer to Neighborhood's Guidance Summary Grid for In Lieu of Services, plan-specific Prior Authorization Reference page, and Clinical Medical Policies for additional information.

Codes and Visit Limits

Acupuncturist codesCPTCovered

97810	Acupuncture, 1 or more needles; without electrical stimulation, initial 15 minutes of personal one-on-one contact with the patient.
97811	Acupuncture, 1 or more needles; without electrical stimulation, each additional 15 minutes of personal one-on-one contact with the patient, with re-insertion of needle(s) (List separately in addition to code for primary procedure)
97813	Acupuncture, 1 or more needles; with electrical stimulation, initial 15 minutes of personal one-on-one contact with the patient.
97814	Acupuncture, 1 or more needles; with electrical stimulation, each additional 15 minutes of personal one-on-one contact with the patient, with re-insertion of needle(s) (List separately in addition to code for primary procedure)

Massage therapist / therapy codesCPTCovered

97124	Therapeutic procedure, 1 or more areas, each 15 minutes; massage, including effleurage, petrissage and/or tapotement (stroking, compression, percussion).
97110	Therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility.
97112	Therapeutic procedure, 1 or more areas, each 15 minutes; neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities.
97140	Manual therapy techniques (eg, mobilization/ manipulation, manual lymphatic drainage, manual traction), 1 or more regions, each 15 minutes.

Chiropractor codesCPTCovered

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

inv-05: Chiropractic visits limit

Annual visit limit12 visits per rolling year

Daily unitsLimited to 1 unit of listed chiropractic codes per day

ScopeChiropractic services provided as In Lieu of Services (see policy statement)

inv-06: Acupuncture visits limit

Annual visit limit12 visits per rolling year

Assistant reimbursementAcupuncture assistants will not be separately reimbursed

Prior Authorization and Attestation

Prior Authorization

Prior Authorization / Attestation — Use Neighborhood In Lieu Of Prior Authorization Request Form

Use the Neighborhood In Lieu Of Prior Authorization Request Form to attest that the requested service is being used 'in lieu of' the described State Plan Service. The requesting provider must verify member eligibility, coverage, and authorization criteria prior to rendering services.

All services must be medically necessary to qualify for reimbursement.
Neighborhood may use NCD, LCD, InterQual, EOHHS recommendations, and Neighborhood CMPs to determine medical necessity.
Contact Provider Services at 1-800-963-1001 for additional details.

Key Definitions

inv-09: Alternative services provided as substitutes for state plan services when medically appropriate and approved by EOHHS

DefinitionAlternative services provided as substitutes for state plan services when medically appropriate and approved by EOHHS

AuthorityServices are utilized with approval from the Rhode Island Executive Office of Health and Human Services (EOHHS)

Optional provisionNeighborhood may, but is not required to, provide In Lieu of Services