Coronavirus Update

Neighborhood’s Temporary COVID-19 Prior Authorization Policy was updated December 2, 2020, in accordance with Health Bulletin 2020-08, issued by OHIC on November 24, 2020.  This policy replaces the former Temporary COVID-19 Prior Authorization Policy, set to be in effect through the earlier of December 31, 2020 (or an extension or shortening of the December 31, 2020 date issued by OHIC as necessary).   Below are specific provisions of the updated policy by Neighborhood line of business:

Medical Services – Medicaid and INTEGRITY

Effective July 1, 2020, prior authorizations will not be required for the following services:

• Non-pharmacy COVID-19 related diagnostic and treatment services

Outpatient and Pharmacy Authorization processes remain in effect.

Medical Services – Commercial

Effective December 1, 2020 through the earlier of February 28, 2021 or the expiration of the Executive Order, prior authorizations will not be required for the following services when the admission date (including transfer date) occurs within the effective date of the policy:

• Inpatient Acute Care level of care determinations
• Skilled Nursing Facilities
• Inpatient Rehabilitation
• Long Term Care Facilities
• In-patient COVID-19 related treatment in out-of-network facilities
• Non-pharmacy COVID-19 related diagnostic and treatment services

Neighborhood will require notification for all admissions and transfers to track and serve members admitted to inpatient facilities, as that is the current process. Notification of admission or transfer can be faxed directly to Utilization Management (UM) Department. The fax number is 1-401-459-6023.

Neighborhood reserves the right to perform retrospective reviews and concurrent reviews. Pharmacy Authorization processes remain in effect.

Behavioral Health Services – Medicaid and INTEGRITY

Effective April 1, 2020 through January 17, 2021, prior authorization will not be required for the following services when the admission date (including transfer date) occurs within the effective date of the policy:

• Inpatient Services
• Outpatient Services

Effective January 18, 2021, prior authorizations will not be required for the following services that occur within the effective date of this policy:

• Non-pharmacy COVID-19 related diagnostic and treatment services

Behavioral Health Services – Commercial

Prior Authorizations will not be required for the following services when the admission date (including transfer date) occurs within the effective date of this policy:

• Inpatient Services
• Outpatient Services

Neighborhood’s vendor requires notification for all admissions and transfers. Neighborhood reserves the right to perform retrospective reviews and concurrent reviews. For the most current information, Behavioral Health providers should contact OPTUM Provider Express.

The Rhode Island Department of Health (RIDOH) recommends COVID-19 testing for:

• People with symptoms of COVID-19
• People who may have been exposed to someone with COVID-19
• Certain asymptomatic populations.

Test Ordering Options

Outpatient healthcare providers can order COVID-19 tests for patients in the following ways:

• Use the online ordering system at ri.gov to order a test for a patient who has symptoms or may have been exposed to someone with COVID-19. The ordering clinician may choose from a list of State-run testing sites located throughout Rhode Island. VIEW STEPS
• Refer patients to a local respiratory clinic for COVID-19 testing.
• Primary care providers and respiratory clinics performing in-office specimen collection and sending tests to a lab for processing should order tests according to the office’s or lab’s protocol.
• Additional testing options for pediatric patients are noted below.

RIDOH encourages facilities that have the capacity to conduct point-of-care testing to contact test kit manufacturers directly to place an order. RIDOH has a limited supply of BinaxNOW rapid antigen test kits that are available to some clinics. To see if your facility qualifies to receive some of these tests, email ridoh.providerquestions@health.ri.gov.

Health care workers who are not able to get tested through their employers can use the testing options above.

Connecticut and Massachusetts healthcare providers caring for Rhode Island residents can gain access to Rhode Island’s online ordering portal by emailing ridoh.providerquestions@health.ri.gov. Rhode Island providers seeing Massachusetts patients can refer those patients to testing through a Respiratory Clinic or in their home state as needed.

All Rhode Islanders can also self-schedule a COVID-19 test on portal.ri.gov, regardless of whether they have symptoms or if they have been identified as a close contact of someone with COVID-19.

For more information about COVID-19 testing in Rhode Island, including an up-to-date list of testing sites and guidance about testing for different populations, visit health.ri.gov/covid/testing.

Pediatric Patient Testing

Providers may use the online ordering system at schedulecovidtest.ri.gov to schedule a COVID-19 test for a pediatric patient. The parent or caregiver may be asked to swab children younger than age 12 with coaching from the staff at the testing site.

This page has information about clinics that offer COVID-19 testing for children. Note that some locations have restrictions on the age groups that can be tested.

Parents can also schedule a COVID-19 test for a child enrolled in a K-12 public or private school by calling the K-12 test scheduling service at 844-857-1814. This program is reserved for K-12 students and staff members who are symptomatic or have been identified as a close contact of a positive case. Pre K students and staff must be part of a Pre K program that is associated with an elementary school to be eligible for this testing program. MORE INFORMATION

Effective January 1, 2021, ICD-10 diagnosis code Z20.822 is replacing previously used code Z20.828 in the following instances:

Claims for exposure to someone with a confirmed case of COVID-19 should be billed with the following ICD-10-CM code:

• Dates of service April 1, 2020 to December 31, 2020:

Z20.828 (Contact with and (suspected) exposure to other viral communicable diseases)

• Dates of service January 1, 2021 and after:

Z20.822 (Contact with and (suspected) exposure to COVID-19

Claims for members presenting with symptoms of and being screened for COVID-19 and the test results are either unknown or negative should be billed with the following ICD-10-CM codes as applicable:

• R05 (Cough)
• 02 (Shortness of breath)
• 9 (Fever, unspecified)
• 818 (Encounter for observation for suspected exposure to other biological agents ruled out)
• 828 (Contact with and (suspected) exposure to other viral communicable diseases) –Effective April 1, 2020 to December 31, 2020
• 822 (Contact with and (suspected) exposure to COVID-19)- Replaces Z20.828 Effective January 1, 2021
• Effective 1/1 CPT Code U0005 is a covered PCR and Antigen Testing code

For more information, go to: https://www.cdc.gov/nchs/data/icd/Announcement-New-ICD-code-for-coronavirus-19-508.pdf

The Rhode Island Department of Health (RIDOH) has created community partner activation briefs, which offer ways that healthcare providers and organizations can get involved in sharing the RIDOH message related to the COVID-19 vaccine.

In addition, the Ad Council and the COVID Collaborative have released a new resource designed to address healthcare professionals’ questions about COVID-19 vaccination. Organized in the form of a toolkit, the resource includes videos (featuring Dr. Anthony Fauci and other leading healthcare and medical experts), a press release, FAQ’s, talking points, social media posts and many customizable materials. Topics addressed include safety, availability, cost, side effects, vaccine administration, answering patients’ questions and more. Find the toolkit on the National Public Health Information Coalition (NPHIC) website: https://www.nphic.org/cvirus-adcouncil-toolkit

Prior authorization is not required for services under the Temporary COVID-19 Telemedicine/Telephone-only Services payment policy , however, we expect our provider community to practice in good faith and use their professional judgement related to services that can be provided through the expanded temporary policy.

Neighborhood expanded its existing payment policy for telemedicine services temporarily during the COVID-19 pandemic. The payment policy is not limited to telephone only. Neighborhood encourages all providers to use HIPAA-compliant technology when available, but recognizes in some cases this may ne be possible. If using alternative options, Neighborhood requests that providers implement reasonable HIPAA safeguards. For more information, please visit: https://www.hhs.gov/sites/default/files/telehealth-faqs-508.pdf

All member cost share for behavioral health services are waived under the new expanded telemedicine/telephone-only payment policy.  In office visits are BAU.

Neighborhood works closely with state agencies to ensure our business practices align with the Governor’s Executive Orders, as well as, direction from CMS, EOHHS, OHIC, and the Rhode Island Department of Health.  This website is frequently updated based on the most recent guidance for our provider network.  Providers can contact their Neighborhood Provider Relations Representative with any additional questions or concerns.

Yes, Neighborhood has temporarily waived the PCP assignment/requirement, beginning April 1, 2020.  This means a Neighborhood member can see any primary care provider they can access during the COVID-19 pandemic for their healthcare, regardless of the PCP name assigned on the member’s Neighborhood ID card.

As a reminder, Neighborhood does not require referrals for any service.

Effective April 1, 2020 Neighborhood and our DME partner DMEnsion/Integra  are temporarily allowing 90-day benefit exceptions, in select cases, for Automatic Blood Pressure Monitors and Electronic Scales, ensuring  the most at-risk members are able to receive services they need to remain comfortable in their homes.

Effective 4/1/2020 through 2/28/2021, the following services will not require authorization when prescribed by a physician for the listed diagnoses. Please note a prescription is still required.

Neighborhood Benefit Exception for Automatic Blood Pressure Monitors and Electronic Scales

On behalf of Neighborhood and DMEnsion/Integra, we are grateful for our DMEPOS providers on the front lines.  We acknowledge that the COVID-19 pandemic is having an impact on the health of family members, friends, the businesses on which we rely, and the global economy. Our thoughts are with those affected in this unprecedented time.  Please contact the DMEnsion Benefit Management Customer Service team, servicing Neighborhood providers at 866-205-2122 with any questions.

Neighborhood is grateful for healthcare professionals willing to obtain an emergency medical license in Rhode Island to help during the COVID-19 crisis.  Neighborhood has developed a process for credentialing and re-credentialing providers during this state of emergency.  The process aligns with the RIDOH for licensing providers who meet the criteria outlined in the regulations, to practice during the COVID-19 crisis.   Neighborhood’s Credentialing Department is continuously monitoring changes published by the RIDOH and CMS to best address network needs.

Yes, dispensing pharmacists will be able to enter overrides at the pharmacy at point of sale. The guidelines below have been put in place to allow for medication access, but to also prevent situations like stockpiling. Pharmacies should call their help desk if they experience any issues processing prescriptions.

• The coding will enable dispensing pharmacists to enter a submission clarification code (SCC13) at the pharmacy to bypass the refill-too-soon (RTS) rejections.
• Medicaid and Exchange plans that have a maximum day supply (DS) of 30 at retail will be able to obtain up to three, 30 days supply early fills.
  • Members will have a maximum of 3 fills within a 90-day window. Members can request all 3 fills at once, but they would have to wait another 90 days to obtain the SSC13 RTS benefit again. Please note that consecutive filling is at the discretion of the dispensing pharmacist. For example, if there is limited inventory of medications at that pharmacy, the pharmacist may not be able to dispense all 3 fills at once.
  • **Controlled substances and Specialty medications are excluded**
• Exchange plans that have a maximum day supply of 90 at retail will be able to obtain a 1-time 90 DS early refill.
  • **Controlled substances and Specialty medications are excluded**
• MMP plans have early refill benefits, but no restriction on number of fills at this time.

Neighborhood’s retro authorization procedures were revised and shared with providers in December 2019: https://www.nhpri.org/providers/communication/provider-newsletter/neighborhood-news-2019/december-2019/updated-retro-authorization-procedures/

This revised policy included extenuating circumstances in which Neighborhood’s Utilization Management (UM) department will accept requests up to 14 days from the date of service. Given the current pandemic, the “Not Enough Time” situation would certainly apply and the UM staff has been made aware.

Neighborhood will waive the cost of the diagnostic testing and treatment for COVID-19.  Neighborhood has developed a Temporary COVID-19 Testing Services payment policy  for billing diagnostic testing services  and treatment related to COVID-19.

Per the Office of the Health Insurance Commission (OHIC) and the Rhode Island Medicaid Program, where applicable, Neighborhood has implemented a Temporary COVID-19 Triage Services Provided Via Telephone Only payment policy to support coverage of telephonic triage for COVID-19.

For Neighborhood’s Commercial members, cost-sharing will be waived.

Neighborhood does not require referrals for any service.

Neighborhood is actively engaged with the Rhode Island Department of Health (RIDOH) and other regulatory agencies.  In addition, Neighborhood is:

• Educating members on steps they can take to prepare and stay healthy.
• Directing members to CALL their provider if they exhibit symptoms.
• Creating a web page, offering information from the Centers for Disease Control and Prevention (CDC) and RIDOH, including the local COVID-19 Info Line 401-222-8022 (available Monday through Friday, 8:30 a.m. to 4:30 p.m.) and email: RIDOH.COVID19Questions@health.ri.gov
• Continuously monitoring COVID-19 developments and assessing whether emergency preparedness plans and modifications to plan practices need to be implemented.