CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Out-of-Network Provider Coverage and Reimbursement

Governs Neighborhood Health Plan of Rhode Island's coverage and reimbursement methods for services rendered by out-of-network providers across Medicaid, INTEGRITY, and Commercial lines.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyOut-of-Network Provider Coverage and Reimbursement

Policy CodePolicy N/A

Change TypeQPA language addedformatting updates

Effective DateDec 11, 2019

Next Review DateN/A

Key ActionVerify eligibility, coverage and authorization criteria prior to rendering services and submit complete claims within timely filing guidelines.

SourceLink

POLICY UPDATE CHANGES

Updated format and added Qualifying Payment Amount (QPA) language.

Disclaimer updated and format updated.

3Lines of business covered

6 monthsContinuity of Care max

1 yearActive Treatment cap

05/02/22Last review

Out-of-Network Reimbursement by Line of Business

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Medicaid reimbursement rules

Medicaid: reimbursement for emergency and covered services during Continuity of Care or by out-of-network providers:

Payment method (any one of)

Neighborhood's usual and customary rate for out-of-network providers.
A rate negotiated between Neighborhood and the out-of-network provider.
If the provider's billed rate is less than Neighborhood's usual and customary rate, the provider's billed rate will be paid.

Termination of the provider agreement shall not affect the method of payment or reduce the amount of reimbursement to the provider by Neighborhood for any patient during the Active Treatment Period; member hold harmless provisions continue in effect during the Active Treatment Period.

Commercial reimbursement rules

Commercial: reimbursement rules and No Surprises Act compliance:

For out-of-network emergency department services, out-of-network air ambulance services, and services rendered by an out-of-network provider at an in-network facility, reimbursement will be determined using the Qualifying Payment Amount (QPA) methodology per Section 102 of the No Surprises Act.

INTEGRITY reimbursement rules

INTEGRITY: reimbursement for emergency and covered services during Continuity of Care or by out-of-network providers:

Payment method (any one of)

Neighborhood's usual and customary rate for out-of-network providers.
A rate negotiated between Neighborhood and the out-of-network provider.
Rates will be inclusive of the Medicare Merit-Based Incentive Payment System (MIPS) adjustment.
If the provider's billed rate is less than Neighborhood's usual and customary rate, the provider's billed rate will be paid.

Required Coding and Payment Methodology

Required coding systemsmixed

CPT	Current Procedural Terminology coding standards required
ICD-10-CM	Diagnosis coding required
HCPCS	HCPCS Level II coding required

Payment methodology for out-of-network (inv-05)

Primary payment optionsPay Neighborhood's usual and customary rate for out-of-network providers, or a rate negotiated between Neighborhood and the out-of-network provider.

If provider billed rate is lowerIf the provider's billed rate is less than Neighborhood's usual and customary rate, Neighborhood will pay the provider's billed rate.

INTEGRITY-specific adjustmentFor INTEGRITY line, rates will be inclusive of the Medicare MIPS adjustment.

Provider Responsibilities and Prior Authorization

Documentation Required

Verify eligibility and timely claim submission

It is the provider's responsibility to verify member eligibility, coverage and any authorization criteria before rendering services, and to submit complete claims for payment within contractually determined timely filing guidelines.

Verify eligibility, coverage and authorization criteria prior to rendering services.
Submit complete claims for payment within contractually determined timely filing guidelines.
Use CPT, ICD-10-CM and HCPCS Level II coding standards when preparing claims.

Prior Authorization

Prior authorization reference

Refer to Neighborhood's plan-specific Prior Authorization Reference page for all prior authorization requirements and details.

See: https://www.nhpri.org/providers/policies-and-guidelines/prior-authorization-reference-guide/ for plan-specific prior authorization rules.

Key Definitions

Active Treatment Period (inv-08)

DefinitionActive Treatment Period: patient in active treatment for an acute medical condition at the time the provider terminates their Agreement until treatment concludes or, if earlier, one (1) year after termination.

Effect of terminationTermination of the provider agreement does not affect the method of payment or reduce reimbursement to the provider for any patient during the Active Treatment Period.

Provider obligations during periodDuring the Active Treatment Period, the provider remains subject to all terms and conditions of the terminated agreement, including reimbursement and member hold harmless provisions.

Continuity of Care Period (inv-09)

Definition and maximum lengthContinuity of Care Period: continued member access for a limited period, not to exceed six months, for medically necessary care and services to prevent disruption during transition.

When appliesApplies to Emergency Services and Covered Services rendered during a Continuity of Care Period and/or by out-of-network providers.

Reimbursement during periodSuch services will be reimbursed less any applicable cost-sharing, using Neighborhood's usual and customary rate or negotiated rate (or provider billed rate if lower).

Covered Services (inv-10)

DefinitionCovered Services: medically necessary inpatient, outpatient, professional, and ancillary health care services and supplies provided to members under the member's benefit plan.

Reimbursement contextCovered Services rendered during a Continuity of Care Period and/or by out-of-network providers will be reimbursed less any applicable cost-sharing and per the payment methodology (usual and customary, negotiated, or billed rate if lower).

Applies across lines of businessPolicy language applies to Medicaid and INTEGRITY lines (and Commercial with QPA rules referenced elsewhere) for out-of-network and continuity scenarios.

Emergency Services (inv-11)

DefinitionEmergency Services: a medical condition with acute symptoms of sufficient severity that a prudent layperson could reasonably expect absence of immediate medical attention to result in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of any bodily organ or part.

Treatment and reimbursementEmergency Services rendered during a Continuity of Care Period and/or by out-of-network providers will be reimbursed less any applicable cost-sharing and per the payment methodology described in the policy.

Member protections during Active TreatmentTermination of provider agreement does not reduce reimbursement for patients receiving Emergency Services during the Active Treatment Period; member hold harmless provisions continue in effect.