CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Newborn coverage and payment requirements

Governs Neighborhood Health Plan of Rhode Island's coverage and reimbursement requirements for newborn services across Medicaid (excluding EFP), INTEGRITY, and Commercial lines; applies to providers submitting claims and seeking authorization for inpatient admissions and NICU transfers.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyNewborn coverage and payment requirements

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization for inpatient admission and for transfer of a newborn to a Neonatal Intensive Care Unit (NICU).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

30 daysclaims under mother's ID window

170-174newborn nursery revenue codes

Auth requiredinpatient/NICU transfer

5Medicaid FFS scenarios

Newborn Coverage Criteria

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ALL of the following

Medical necessity: All services must be medically necessary to qualify for reimbursement. Neighborhood may use NCD, LCD, InterQual, Rhode Island EOHHS recommendations, and Clinical Medical Policies to determine medical necessity.
Authorization: Authorization is required for the inpatient hospital admission and for the transfer of a newborn to a Neonatal Intensive Care Unit (NICU). Providers should refer to Neighborhood's plan-specific Prior Authorization Reference page and Clinical Medical Policies.
Documentation: Neighborhood reserves the right to request medical records for any service billed. Documentation must support the services billed and the medical necessity of those services and shall follow CMS standards for proper documentation requirements.
Claim submission timing and identifiers: Providers must submit complete claims within contractual timely filing guidelines. Neighborhood will accept claims submitted under the mother's member ID number for the first 30 days of a newborn's life; after 30 days claims must be submitted under the newborn's member ID number.
Coding and claim content requirements: Coding must meet AMA CPT, ICD-10-CM, and HCPCS Level II standards. Submit a Present on Admission (POA) indicator for each diagnosis code when applicable. A birthweight must be submitted on the UB-04 to allow correct DRG calculation.
Newborn nursery billing: Providers must file a separate claim for newborn nursery charges using appropriate revenue codes for newborn services (revenue codes 170–174 for Nursery and Newborn levels I–IV).
Provider routing and special scenarios
- Submit claims to Medicaid Fee-For-Service in the following scenarios: delivery at Women & Infants (W&I) with admission to W&I NICU; delivery at W&I with admission to W&I NICU and discharge to Hasbro, Boston Children's Hospital, or Mass General with readmission to W&I NICU after treatment; delivery at non-W&I facility with direct admission to W&I NICU; delivery at non-W&I facility with direct admission to W&I NICU and discharge to Hasbro, Boston Children's Hospital, or Mass General with readmission to W&I NICU after treatment; transfer from W&I Normal Newborn Nursery to W&I NICU.
Benefit applicability: This policy applies to Medicaid (excluding Extended Family Planning), INTEGRITY, and Commercial lines; commercial members may have cost-sharing (coinsurance, copays, deductibles) per plan design.

Operational note: It is the provider's responsibility to verify eligibility, coverage and authorization criteria prior to rendering services and to contact Provider Services at 1-800-963-1001 with questions.

Coding and Billing Requirements

Newborn nursery revenue codesRevenueCovered

170	Nursery - General Classification
171	Newborn level I - special care nurse
172	Newborn level II - NICU level II
173	Newborn level III - NICU level III
174	Newborn level IV - NICU level IV

Coding standardsmixed

No codes listed

Birthweight submission requirement

RequirementBirthweight must be submitted on the UB-04 claim form so the DRG can be calculated correctly.

When to submitInclude birthweight on all newborn inpatient claims where DRG assignment applies, in accordance with industry standards.

Claim formUB-04 (Uniform Billing) is the required form for reporting birthweight for DRG calculation.

Related filing guidanceProviders may submit newborn claims under the mother's member ID for the first 30 days; birthweight still must be included on the UB-04.

Provider Actions and Requirements

Prior Authorization

Prior authorization required for inpatient admission and NICU transfer

Authorization is required for the inpatient hospital admission and for the transfer of a newborn to a Neonatal Intensive Care Unit (NICU). Providers should refer to Neighborhood's plan-specific Prior Authorization Reference page and Clinical Medical Policies for details and verify eligibility, coverage and authorization criteria prior to rendering services.

Documentation Required

Documentation must support billed services; records may be requested

Neighborhood reserves the right to request medical records for any service billed; documentation in the medical record must support the service(s) billed and the medical necessity of the service(s). Neighborhood follows CMS standards for proper documentation and may audit records to validate billed services.

Key Definitions

Definition of medically necessary

DefinitionMedically necessary services are those that meet Neighborhood's criteria which may include NCD, LCD, InterQual, Rhode Island EOHHS recommendations, and Clinical Medical Policies.

Sources used to determine medical necessityNational Coverage Determination (NCD); Local Coverage Determination (LCD); InterQual; Rhode Island EOHHS recommendations; Clinical Medical Policies (CMP).

Provider responsibilityProviders must verify eligibility, coverage and authorization criteria prior to rendering services.

Authorization implicationAuthorization is required for inpatient hospital admission and for transfer of a newborn to a NICU when medically necessary.

Present on Admission (POA) indicator

POA submissionSubmit a Present on Admission (POA) indicator for each diagnosis code when applicable.

ApplicabilityPOA indicators should be reported on UB-04 claims for inpatient stays where diagnosis codes require POA reporting.

Coding standardsPOA reporting is part of complete claims submission which must meet CPT, ICD-10-CM, and HCPCS Level II coding standards.