CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Reminder: Claims Processing Policy for Modifier 25

Reminds providers of Neighborhood Health Plan of Rhode Island's claims processing rules for appending Modifier 25 to Evaluation and Management (E/M) claims and explains documentation and submission expectations for denied claims; affects providers submitting claims to Neighborhood.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyClaims Processing Policy for Modifier 25 (reminder)

Policy CodePolicy N/A

Change TypeAdministrative reminder

Effective DateMar 26, 2024

Next Review DateN/A

Key ActionIf a claim is denied for lack of medical note review, submit supporting documentation via Neighborhood's reconsideration process.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1policy reminder document

1-800-963-1001phone contact

2024-03-26effective date

Modifier 25 Processing Rules

Modifier 25 processing rules

Processing and documentation stance for Modifier 25 claims:

Modifier 25 should be used only with Evaluation and Management (E/M) codes and not appended to surgical procedure codes.

Modifier 25 denotes a significant, separately identifiable E/M service performed by the same physician or qualified health care professional on the same day as another procedure or service.

Claims are subject to claim edits that are updated regularly; medical notes may be required when using modifiers to determine medical necessity and to correctly process the claim.

If a claim is denied due to the need for a medical note review, providers should submit supporting documentation through Neighborhood's reconsideration process.

Modifier Usage and Documentation

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyClaims Processing Policy for Modifier 25 (reminder)

Policy CodePolicy N/A

Change TypeAdministrative reminder

Effective DateMar 26, 2024

Next Review DateN/A

Key ActionIf a claim is denied for lack of medical note review, submit supporting documentation via Neighborhood's reconsideration process.

SourceLink

On This Page

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.

Modifier usageModifier

Modifier 25

Used when a significant separately identifiable E/M service is performed by the same physician or other qualified health care professional on the same day as a procedure or other services; should be used with E/M codes only and not appended to surgical procedure code(s).

Documentation requirement — medical notes

RequirementMedical notes may be required to correctly process claims when using modifiers; providers should be prepared to submit documentation to support modifier use.

When to submitIf a claim is denied due to the need for a medical note review, submit supporting documentation through Neighborhood's reconsideration process.

Supporting policyClaims are subject to claim edits that are updated regularly; medical notes may be required on certain modifiers to determine medical necessity per Neighborhood's Modifier Payment Policy.

What Providers Should Do

Documentation Required

Documentation Submission on Denial

If a claim is denied because a medical note review is needed, submit the supporting documentation through Neighborhood Health Plan of Rhode Island's reconsideration process so the claim can be re-evaluated.

Submit all relevant medical notes and documentation with the reconsideration request.
Include dates of service, E/M code(s), procedure code(s), and explanation of why Modifier 25 was appropriate.

Note

Provider Support Contact

For questions about this policy or the reconsideration process, contact Provider Services at 1-800-963-1001. Visit the Policies and Guidelines section of Neighborhood's website for additional policy details.

Provider Services: 1-800-963-1001

Modifier Definitions

Modifier 25 — definition and usage

DefinitionModifier 25 is used when a significant separately identifiable E/M service is performed by the same physician or other qualified health care professional on the same day as a procedure or other service.

Usage restrictionModifier 25 should be used with E/M codes only and not appended to surgical procedure code(s).

Processing noteClaims with Modifier 25 may be subject to claim edits and documentation requests to determine medical necessity.