CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Billing and documentation guidelines for Spravato (esketamine) administration

Defines Neighborhood Health Plan of Rhode Island's billing, coding, documentation, and reimbursement expectations for administration and monitoring of Spravato for behavioral health providers, clinical staff, and administrative personnel across specified lines of business.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyBilling and documentation guidelines for Spravato (esketamine) administration

Policy CodePolicy N/A

Change TypeTemplate and member/disclaimer updates

Effective DateMar 1, 2026

Next Review DateN/A

Key ActionMaintain medical record documentation that supports billed services and applicable time-based E/M and prolonged service codes to meet medical necessity and billing requirements.

SourceLink

POLICY UPDATE CHANGES

Updated policy template to include new lines of business and updated Member Responsibility and Disclaimer language.

Set policy effective date to 03/01/2026.

4Primary CPT/HCPCS codes listed

3Lines of business explicitly included

0Prior authorization rules specified in this document

Policy at-a-glance

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.

This policy defines Neighborhood Health Plan of Rhode Island's billing, coding, documentation, and reimbursement expectations for the administration and monitoring of Spravato (esketamine) for behavioral health providers, clinical staff, and administrative personnel. It applies across Neighborhood's commercial, Medicaid (excluding EFP), and Dual lines of business including Neighborhood CONNECT (Coordination only D-SNP) and INTEGRITY for Duals.

For questions about policy interpretation or claims submission, contact Provider Services at 1-800-963-1001. This payment policy is informational and not a guarantee of reimbursement; payments remain subject to member eligibility, benefit coverage, coding, documentation, authorization, contract terms, and applicable state and federal regulations, and Neighborhood may update the policy at any time.

PayerNeighborhood Health Plan of Rhode Island

PolicyBilling and documentation guidelines for Spravato (esketamine) administration

Effective Date2026-03-01

Last Review2026-01-01

StatusCURRENT

ScopeDefines Neighborhood Health Plan of Rhode Island's billing, coding, documentation, and reimbursement expectations for administration and monitoring of Spravato for behavioral health providers, clinical staff, and administrative personnel across specified lines of business.

Applicable CPT / HCPCS Codes

Evaluation and Management and prolonged service codes applicable for Spravato encountersCPT|HCPCSCovered

99205	Office or other outpatient visit for evaluation and management of a new patient; high level medical decision making. Total time threshold: 60 minutes when using total time for selection.
99215	Office or other outpatient visit for evaluation and management of an established patient; high level medical decision making. Total time threshold: 40 minutes when using total time for selection.
99415	Prolonged clinical staff service, first hour (in addition to E/M service) with direct patient contact and physician supervision.
99416	Prolonged clinical staff service, each additional 30 minutes (in addition to E/M service).
G2212	Prolonged office/outpatient E/M service beyond the maximum required time of the primary procedure; each additional 15 minutes. Applicable only for INTEGRITY for Duals and Dual CONNECT.

This document provides billing rules for Spravato encounters, including selection of the appropriate E/M code based on total time and the reporting of prolonged service codes only when time thresholds are exceeded. Neighborhood applies Correct Coding Initiative (CCI) edits and may request medical records to support billed services; providers must retain documentation that supports the services billed and medical necessity.

Documentation, Billing, and Authorization Requirements

Documentation Required

Support billing with medical record documentation

Maintain medical record documentation that supports the service(s) billed and medical necessity; Neighborhood may request records and follows CMS documentation standards.

Affected codes: 99205, 99215, 99415, 99416, G2212

Billing Rule

E/M code selection and prolonged services billing

Select the appropriate E/M code based on total time spent. Prolonged service codes may only be reported in addition to the highest-level E/M code billed when the applicable time thresholds are exceeded; follow unit and combination restrictions for G2212.

Applicable codes: 99205 (total time threshold: 60 minutes), 99215 (total time threshold: 40 minutes), 99415, 99416, G2212
G2212: report only for units of 15 minutes or more; do not report G2212 on same date as 99358, 99359, 99415, or 99416

Prior Authorization

Verify eligibility and prior authorization

Providers are responsible for verifying member eligibility, coverage, and authorization criteria prior to rendering services; Neighborhood may reference NCD, LCD, InterQual, EOHHS recommendations, and Clinical Medical Policies when determining medical necessity.

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

Billing Rule

CCI edits and claim denials

Neighborhood applies Correct Coding Initiative (CCI) edits; CPT codes billed outside the listed ones may be subject to denial.

Codes outside the listed Evaluation and Management and prolonged service codes may be denied per CCI edits

Billing Rule

Timely filing and contractual rules

Submit complete claims for payment within contractually determined timely filing guidelines; billable services are subject to contractual agreements.

Claims must meet timely filing requirements per provider contract; services are subject to contractual rules

Time and unit thresholds

Total time threshold for CPT 9920560 minutes

Total time threshold for CPT 9921540 minutes

Minimum time unit for G221215 minutes

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyBilling and documentation guidelines for Spravato (esketamine) administration

Policy CodePolicy N/A

Change TypeTemplate and member/disclaimer updates

Effective DateMar 1, 2026

Next Review DateN/A

Key ActionMaintain medical record documentation that supports billed services and applicable time-based E/M and prolonged service codes to meet medical necessity and billing requirements.

SourceLink

On This Page

OpenPayer

Billing and documentation guidelines for Spravato (esketamine) administration

Policy at-a-glance

Applicable CPT / HCPCS Codes

Medical Necessity / Coverage Logic

Documentation, Billing, and Authorization Requirements

Defined Terms

Clinical and Administrative Context

Policy Update Changes