CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Non-Covered Services Payment Policy

Defines services and procedure codes that Neighborhood Health Plan of Rhode Island designates as non-covered and payment exclusions effective January 1, 2023; applies to Neighborhood Health Plan lines of business including Medicaid, Commercial, and INTEGRITY where specified.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyNon-Covered Services Payment Policy

Policy CodePolicy N/A

Change TypeCode additions and removalsexclusions revised

Effective DateJan 1, 2023

Next Review DateN/A

Key ActionProviders should reference the updated non-covered list when billing following the January 1, 2023 effective date.

SourceLink

POLICY UPDATE CHANGES

A set of CPT/HCPCS codes were added to the non-covered list for all lines of business.

A set of CPT/HCPCS codes were added to the non-covered list for Medicaid.

Certain codes were removed from the non-covered list for INTEGRITY.

Certain codes were removed from the non-covered list for Medicaid.

Certain codes were removed from the non-covered list for Commercial.

Policy text updated to add investigational/experimental services and adjust exclusions for homemaker services, home births, and respite.

1policy effective date(s) referenced

~70+Medicaid codes added

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Non-Covered Services and Exclusions

This policy lists specific procedure and HCPCS codes designated as non-covered for specified lines of business and describes additional exclusion language changes.

ALL of the following

ALL of the following
- 81514
- 0289U to 0294U
- 0301U to 0322U
- 0671T to 0692T
- A2001 to A2013
- A4100
- A9291
- A9595
- C1832
- C1833
- C9781 to C9783
- G0028 to G0058
- H2038
- K1028 to K1030
- T2050
- T2051

ALL of the following

ALL of the following
- 0001U
- 0002M
- 0002U
- 0003M
- 0003U
- 0004M

ALL of the following

ANY of the following
- C9764 to C9767
- C9772 to C9775
- 99441 to 99444
- Q5115
ALL of the following
- 55874
- 0041A

ALL of the following

Added services for investigational/experimental
Moved commercial homemaker services language to additional coverage exclusions
Moved commercial home births language to additional coverage exclusions
Updated respite exclusion to include Adults (children remain covered)

ALL of the following

Effective January 1, 2023 (annual update)

Procedure and HCPCS Code Lists

Not Covered — All Lines of BusinessmixedNot Covered

81514	molecular pathology procedure
0289U-0294U	proprietary lab codes range
0301U-0322U	proprietary lab codes range
0671T-0692T	temporary tracking codes range
A2001-A2013	HCPCS A2001–A2013 series
A4100	HCPCS A4100
A9291	HCPCS A9291
A9595	HCPCS A9595
C1832	HCPCS C1832
C1833	HCPCS C1833

1–10 of 16

1/2

Not Covered — MedicaidmixedNot Covered

0001U	proprietary code 0001U
0002M	proprietary code 0002M
0002U	proprietary code 0002U
0003M	proprietary code 0003M
0003U	proprietary code 0003U
0004M	proprietary code 0004M
0006M	proprietary code 0006M
0007M	proprietary code 0007M
0200T-0231T	Selected T-codes 0200T–0231T (selected entries included)
0362T	0362T

1–10 of 18

1/2

Removed from Non‑Covered (Now Covered) — IntegritymixedCovered

C9764-C9767	HCPCS C9764–C9767
C9772-C9775	HCPCS C9772–C9775
99441-99444	Telephone evaluation and management codes 99441–99444
Q5115	Q5115

Removed from Non‑Covered (Now Covered) — MedicaidmixedCovered

55874	55874
0041A	0041A
0042A	0042A
91304	91304

Removed from Non‑Covered (Now Covered) — CommercialmixedCovered

99441-99444	Telephone E/M codes 99441–99444
Q5115	Q5115

Provider Notice and Required Actions

Documentation Required

Non-Covered Services Update Notice — Annual update effective January 1, 2023

Neighborhood Health Plan of Rhode Island has completed its annual review of the Non-Covered Services Payment Policy. The revised policy is effective January 1, 2023. Providers must review the updated Non-Covered Services list and take the following actions: update billing and coding practices to reflect the changes; verify that services rendered are billed only when covered; adjust documentation to support medical necessity for services that remain covered; and expect claim denials for services now classified as non-covered.

Effective date: January 1, 2023
Action: Reference the updated Non-Covered Services list before submitting claims
Action: Adjust billing and documentation to reflect removed or reclassified CPT/HCPCS codes
Risk: Claims for services on the non-covered list may be denied and are not payable

Definitions

Definition — Non-covered

DefinitionNon-covered: Services and procedure codes that Neighborhood Health Plan of Rhode Island designates as not covered for payment under the plan; identified by specific CPT/HCPCS codes and exclusions in this policy.

ApplicationApplies to specified lines of business per the policy (Medicaid, Commercial, INTEGRITY) where designated code lists and exclusions indicate non-coverage.

Effective dateDesignations effective January 1, 2023 as part of the annual policy update.

Definition — Investigational/Experimental

DefinitionInvestigational/Experimental: Services considered investigational or experimental are those added to the policy’s exclusions and are not covered for payment under this policy.

Policy actionInvestigational/experimental services were explicitly added to the Non-Covered Services Payment Policy effective January 1, 2023.