CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

New Versus Established Patient Guidelines

Defines criteria for classifying patients as new or established for professional and facility claims (CMS-1500 and UB-92) and describes reimbursement implications; applies to providers submitting claims to Neighborhood Health Plan of Rhode Island.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyNew Versus Established Patient Guidelines

Policy CodePolicy N/A

Change TypeClarified applicability to CMS-1500 and UB-92

Effective DateSep 1, 2010

Next Review DateN/A

Key ActionUse CMS-1500 for professional services and UB-92 for facility services and determine new vs established patient using a 3-year lookback and prior face-to-face encounter.

SourceLink

POLICY UPDATE CHANGES

Format change, minor edits, added language of applicability to both professional and facility claims.

3 yearslookback period to determine new patient status

CMS-1500 & UB-92claim forms covered

all placesplaces of service applicability

face-to-faceencounters that change designation

New vs Established Patient Criteria

New vs Established patient criteria

Covered when the following definitions and conditions determine whether a patient is classified as new or established for reimbursement:

ALL of the following

ALL of the following
- Patient is considered new if not treated within the last three calendar years.
ALL of the following
- 'New' means a new physician or another physician of the same specialty who belongs to the same group practice.
ALL of the following

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyNew Versus Established Patient Guidelines

Policy CodePolicy N/A

Change TypeClarified applicability to CMS-1500 and UB-92

Effective DateSep 1, 2010

Next Review DateN/A

Key ActionUse CMS-1500 for professional services and UB-92 for facility services and determine new vs established patient using a 3-year lookback and prior face-to-face encounter.

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.

Billing and Patient Designation Actions

Billing Rule

Billing form and new/established patient determination

Use the CMS-1500 claim form for professional services and the UB-92 claim form for facility services when submitting claims to Neighborhood Health Plan of Rhode Island. Determine whether a patient is new or established by applying a three-calendar-year lookback: a patient who has not been treated within the last three calendar years is considered new. If no prior face-to-face encounter occurred between the physician and the patient, the first face-to-face encounter may be coded as a new patient. When a physician is on call or covering for another physician, reimburse the encounter as if the member’s regular physician (who was not available) treated the patient. Interpretations of diagnostic tests (for example, x-ray or EKG) without a face-to-face encounter do not change the patient’s new/established designation.

Submit professional services on CMS-1500; facility services on UB-92.
Classify a patient as new if not treated within the last three calendar years (3-year lookback).
If no prior face-to-face encounter exists, the first face-to-face visit may be billed as a new patient encounter.
On-call or covering physicians’ encounters are reimbursed as if the member’s regular physician treated the patient.
Diagnostic test interpretations without face-to-face encounters do not alter new patient status.

Key Definitions

New (physician-level definition)

Physician-level 'New' definition'New' is defined as a new physician or another physician of the same specialty who belongs to the same group practice.

Covering/on-call encountersWhen a physician is on call or covering for another physician, the encounter is reimbursed as if treated by the member's regular physician who was not available.

Diagnostic test interpretationsInterpretation of diagnostic tests (e.g., x-ray, EKG) without a face-to-face encounter does not change 'New' designation.

New patient (time-based)

Time-based definition of New patientA new patient is one that has not been treated within the last three calendar years.

First face-to-face encounterIf no prior face-to-face encounter occurred, the first face-to-face encounter may be coded as a new patient.

Non–face-to-face servicesServices such as interpretations of diagnostic tests without face-to-face contact do not affect new patient status.

OpenPayer

New Versus Established Patient Guidelines

New vs Established Patient Criteria

Claim Forms and Lookback Period

Billing and Patient Designation Actions

Key Definitions