CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Temporary Telemedicine/Telephone-Only Reimbursement Policy

This document governs Neighborhood Health Plan of Rhode Island's temporary reimbursement and billing rules for clinically appropriate telemedicine and telephone-only medical services during the COVID-19 pandemic for participating providers across all lines of business.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyTemporary Telemedicine/Telephone-Only Reimbursement Policy

Policy CodePolicy N/A

Change TypeTemporary expansion; prior auths and member cost share waived

Effective Dateon or after March 18, 2020

Next Review DateN/A

Key ActionDo not collect member cost share for the covered telemedicine/telephone-only services and submit claims with POS 02 and modifier CR within 90 days.

SourceLink

POLICY UPDATE CHANGES

Removed an 'effective until' date per Executive Order 20-18.

Added emergency department as an allowed billing site and clarified OHIC language regarding patient location.

Waived prior authorization requirements for the telemedicine/telephone-only services outlined in this policy.

Waived member cost share for Commercial plans for services outlined in this temporary policy.

100%reimbursement of in-office allowable for telemedicine/telephone encounters

90 daystimeframe to submit claims for payment

POS 02place of service code required

Telemedicine and Telephone-Only Coverage Criteria

Telemedicine/Telephone Coverage Criteria

Telemedicine/telephone-only services are covered when they meet documentation, medical necessity, provider scope, and encounter requirements. Specific inclusions and exclusions 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.

Provider types that may bill for telemedicine/telephone-only services during the temporary period

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

Documentation, authorization, reimbursement and audit

Documentation requirements for a telemedicine/telephone-only service are the same as those required for any face-to-face encounter.
Prior authorization requirements will be waived for the telemedicine/telephone-only services outlined in this policy.
Neighborhood will reimburse telemedicine/telephone encounters at 100% of the in-office allowable for any clinically appropriate, medically necessary covered health service.
Neighborhood reserves the right to audit medical records as well as administrative records to verify the nature of the services provided, the medical necessity and clinical appropriateness to provide such service via telemedicine and/or telephone and the appropriateness of evaluation and management coding.

Exclusions (services not covered via telemedicine/telephone-only)

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

Claim Coding and Reimbursement

Claim coding requirementsmixedCovered

POS 02	Place of Service code indicating telemedicine/telephone-only
CR	Modifier - Catastrophe/Disaster Related

Reimbursement rate — Telemedicine/Telephone encounters

Reimbursement rate100% of the in‑office allowable for telemedicine/telephone encounters

Applies toAny clinically appropriate, medically necessary covered health service provided via telemedicine/telephone

Documentation standardSame documentation requirements as face‑to‑face encounters; permanent record must be maintained in the patient record

Prior authorizationPrior authorization requirements for these services are waived for the timeframe of this policy

Provider Responsibilities and Operational Rules

Prior Authorization

Prior authorization waived for covered telemedicine/telephone services

Prior authorization requirements for the telemedicine/telephone-only services described in this temporary policy are waived.

Documentation Required

Neighborhood audit rights

Neighborhood reserves the right to audit medical and administrative records to verify adherence to the policy, including the nature of services provided, medical necessity, clinical appropriateness for telemedicine/telephone delivery, and coding levels.

Definitions

Telemedicine/telephone-only service — definition and scope

DefinitionDocumented communications in which the patient participates at the time of service and the service meets the same key components as an equivalent face‑to‑face encounter

Coverage criteriaCovered when patient participates at time of service; service amount and nature meet key components of face‑to‑face service; medically necessary and covered by the member's plan; within provider scope of license; permanent record maintained

Exclusions / limitationsServices rendered via email, text, fax, patient portal, same‑day duplicate face‑to‑face visits for same condition, incidental administrative communications, or services not clinically appropriate for telemedicine are excluded

Originating siteProviders may serve patients regardless of originating site, including nursing facilities and inpatient hospitals per OHIC Bulletin

All Medical Specialists — included provider types