CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Durable Medical Equipment (DME) Authorization Requirement Changes - Medicaid and Commercial

This policy updates prior authorization requirements for specific Durable Medical Equipment (DME) HCPCS codes for Neighborhood Health Plan of Rhode Island Medicaid and Commercial members, effective June 1, 2026.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyDME Authorization Requirement Changes - Medicaid and Commercial

Policy CodePolicy N/A

Change TypeAuthorization requirement added for specific HCPCS DME codes

Effective DateJun 1, 2026

Next Review DateN/A

Key ActionObtain prior authorization before submitting claims for the listed HCPCS DME codes; claims without authorization will be denied.

SourceLink

POLICY UPDATE CHANGES

Prior authorization will be required for a specified list of HCPCS DME codes for Neighborhood Medicaid and Commercial members effective June 1, 2026.

Claims submitted without the required authorization will be denied.

~20HCPCS codes newly requiring prior authorization

Jun 1, 2026Effective date

Medicaid & CommercialMember populations

Prior authRequired action

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.

Coverage Criteria

Authorization-contingent coverage

Coverage for the listed HCPCS codes is contingent on obtaining prior authorization beginning June 1, 2026.

Prior authorization must be obtained before submitting claims for the HCPCS codes listed in this policy, effective June 1, 2026.

Claims submitted without the required prior authorization will be denied.

These authorization requirements apply to Neighborhood Health Plan of Rhode Island Medicaid and Commercial members.

HCPCS DME Codes Requiring Prior Authorization

HCPCS DME codes requiring prior authorizationHCPCSCovered

E0302	Extra heavy-duty hospital bed with weight capacity greater than 600 pounds, without mattress
E0467	Multi-function home ventilator used for respiratory support
L0486	Custom fabricated triplanar thoracolosacral orthosis (TLSO), two-piece design with interface liner
L1846	Custom fabricated knee orthosis with double uprights, including thigh and calf components
L1945	Custom molded ankle-foot orthosis (AFO) made of plastic with rigid anterior tibial section
L2036	Knee ankle foot orthosis (KAFO) full plastic double upright custom fabricated
L2037	Custom fabricated KAFO with full plastic design and single upright
L3740	Custom fabricated elbow orthosis with double uprights, adjustable lock, cuffs, and active control
L5673	Addition to a lower extremity prosthesis for a custom fabricated component used with a locking mechanism
L5679	Addition to a lower extremity prosthesis for a custom fabricated component used with a locking mechanism

1–10 of 20

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Provider Actions and Operational Notes

Prior Authorization

Prior authorization required for specified DME HCPCS codes

Beginning June 1, 2026, prior authorization must be obtained before submitting claims for the listed DME HCPCS codes. Claims submitted without the required authorization will be denied.

Applies to Neighborhood Medicaid and Commercial members.
Requirement effective date: June 1, 2026.

Documentation Required

Operational update — authorization grid will be updated

Neighborhood will update the authorization requirements grid prior to the effective date.

Definitions / Notes

Prior authorization (inv-05)

RequirementPrior authorization must be obtained before submitting claims for the listed HCPCS DME codes effective June 1, 2026.

Consequence of noncomplianceClaims submitted without the required prior authorization will be denied.

Member populations affectedNeighborhood Medicaid and Commercial members.

Effective dateJune 1, 2026.

PurposePart of Neighborhood's annual DME review to ensure appropriate utilization of high‑cost equipment and support safe, effective care for members.