CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Temporary expansion of telemedicine/telephone-only services

Temporary reimbursement/payment policy expanding coverage and payment parity for clinically appropriate telemedicine and telephone-only services for Neighborhood Health Plan of Rhode Island members during the COVID-19 emergency; applies to Medicaid (excluding EFP), INTEGRITY, and Commercial lines.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyTemporary expansion of telemedicine/telephone-only services

Policy CodePolicy N/A

Change TypeRevised (emergency implementation, documentation, and coding updates)

Effective DateMar 18, 2020

Next Review DateN/A

Key ActionPrior authorization is waived for telemedicine/telephone-only services; providers must verify eligibility and document visits like face-to-face encounters.

SourceLink

POLICY UPDATE CHANGES

Added emergency department and OHIC language regarding patient location; updated authorization and documentation requirements.

Language regarding implementation, modification, and termination of policy added; removed specific 'effective until' date.

Added New POS 10 under Claim Submission to align with CMS requirement, effective 4/01/2022.

100%reimbursement vs in-office

POS 02, POS 10required POS codes

CRrequired modifier

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.

Telemedicine and Telephone-only Coverage Criteria

Telemedicine Coverage Criteria and Rules

Telemedicine/telephone-only services are covered when ALL of the following criteria are met and when billed by the listed provider types; specified exclusions and operational rules apply.

ALL of the following

The patient is present/participates at the time of service.
Services must be of an amount and nature that would be sufficient to meet the key components and/or requirements of the same service when rendered via face-to-face interaction.
Services must be medically necessary and otherwise covered under the member's benefit plan.
Services must be within the provider's scope of license.
A permanent record of the telemedicine/telephone-only communication(s) must be documented/maintained as part of the patient's medical record; documentation requirements are the same as those required for any face-to-face encounter.
Neighborhood will reimburse telemedicine/telephone encounters at 100% of the in-office allowable for any clinically appropriate, medically necessary covered health service.

Covered provider types

Primary care physicians
All Medical Specialists (MD, DO, NP, PA)
Optometrists
Doctors of Podiatric Medicine (DPM)
Chiropractors (DC)
Lactation Consultants
Physical, Occupational and Speech Therapists

Coverage exclusions and limits

Services rendered through email, text, fax, or patient portal are excluded.
Telemedicine that occurs the same day as a face-to-face visit when performed by the same provider for the same condition is not covered.
Patient communications incidental to E&M services (e.g., test result reporting, educational materials) are excluded.
Administrative interactions (scheduling, registration, billing updates, reminders, medication refill requests, referrals, ordering diagnostics, and patient-completed medical history intake) are excluded.
Any telemedicine/telephonic encounter conducted by office staff, RNs, LPNs, etc., is excluded.
Services that are not clinically appropriate to be billed through telemedicine/telephone (e.g., chiropractor manual manipulation or physical therapist manual therapy) are excluded.

Operational and audit rules

Neighborhood reserves the right to audit medical and administrative records to verify the nature of services provided, medical necessity, appropriateness of telemedicine/telephone provision, and the appropriateness of E&M coding.
Prior authorization requirements will be waived for the telemedicine/telephone-only services outlined in this policy; providers should verify eligibility and coverage prior to rendering services.

Claim Coding, Modifiers, and Reimbursement

Claim coding requirementsmixedCovered

POS 02	Place of Service when patient is not located in their home
POS 10	Place of Service when patient is located in their home (effective 4/1/22)
CR	Modifier: Catastrophe/Disaster Related

Reimbursement parity

Reimbursement rateNeighborhood will reimburse telemedicine/telephone encounters at 100% of the in-office allowable for any clinically appropriate, medically necessary covered health service.

Audit rightsNeighborhood reserves the right to audit medical and administrative records to verify services, medical necessity, and appropriateness of telemedicine and E&M coding.

Documentation parityDocumentation requirements for telemedicine/telephone-only services are the same as those required for any face-to-face encounter.

Prior Authorization, Verification, and Documentation Requirements

Note

Prior Authorization Waived — Verify Eligibility & Maintain Documentation

Prior authorization requirements for the telemedicine and telephone-only services described in this policy are waived. Providers must still verify member eligibility, coverage, and any authorization criteria prior to rendering services and may consult Neighborhood's Prior Authorization Reference page for details. Documentation for telemedicine/telephone-only encounters must be maintained as a permanent part of the medical record and is subject to Neighborhood's right to audit medical and administrative records to verify services, medical necessity, clinical appropriateness for telemedicine/telephone, and E/M coding.

Prior authorization is waived for the telemedicine/telephone-only services outlined in this policy.
Provider responsibility to verify eligibility, coverage and authorization criteria prior to rendering services.
Maintain documentation equivalent to face-to-face encounters as a permanent part of the patient's medical record.
Records are subject to Neighborhood's audit to verify nature of services, medical necessity, appropriateness for telemedicine/telephone, and E/M coding.

Key Definitions

Telemedicine / Telephone-only — definition & scope

DefinitionTelemedicine/telephone-only services: medical services provided via telemedicine or telephone during the COVID-19 pandemic, temporarily expanded per state executive order and OHIC guidance.

ScopeApplies to clinically appropriate telemedicine and telephone-only services when the patient is present/participates at the time of service and services meet the same key components as face-to-face visits.

Exclusions / not considered telemedicineCommunications incidental to E&M, administrative matters, email/text/fax/patient portal, and public-facing video applications are not covered as telemedicine under this policy.

Medical necessity (standards & references)

Medical necessity standardServices must be medically necessary and otherwise covered under the member's benefit plan; Neighborhood follows NCDs, LCDs, industry-accepted criteria, EOHHS recommendations, and Neighborhood Clinical Medical Policies.