Primary Care Prior Authorization Waiver for Commercial Lines of Business
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Defines Neighborhood Health Plan of Rhode Island's implementation of Rhode Island legislation (H5120A / R.I. Gen. Laws §27-18.9-2) that prohibits prior authorization for most medically necessary services ordered by credentialed primary care providers for commercial lines of business; affects in-network PCPs and claims processing for Commercial LOB.
No material clinical or coverage changes in this revision.
When Prior Authorization Is Waived or Required
Prior authorization applicability
Covered without prior authorization when ALL of the following conditions are met; prior authorization is required in the listed exceptions.
ALL of the following
- Service is ordered or rendered by an eligible primary care provider within the normal course of providing primary care
- Ordering provider is enrolled, credentialed, and contracted with Neighborhood
- Ordering provider is the member's assigned PCP or is at the same site (referral circle) as the member's assigned PCP and engaged in clinical decision making for the ordered service
- Claims must include the ordering/referring provider; use modifier 'V1' when the billed service is not rendered by the PCP
Exceptions – prior authorization still required or claim denied
- Pharmacy products and prescription medications (examples: diabetic testing supplies, OTC products) — excluded from the waiver and continue to require prior authorization
- Service is not covered under the member's benefits or is explicitly excluded (including quantity limits) — may trigger denial of payment
- Service is provided by an out-of-network provider or facility — prior authorization required to assess coverage and member financial responsibility per the No Surprises Act
- Provider has a documented history of fraud, waste, or abuse — may still be required to submit prior authorization requests
Claims, Modifiers, and Network Status
| V1 | Modifier required on claims when billed service is not rendered by the PCP but ordered by the PCP (ordering/referring provider must be included). |
Provider Responsibilities and Exceptions
Prior authorization waived for eligible PCP-ordered services
When services or products are ordered or rendered by an eligible PCP within the normal course of providing primary care, prior authorization will be waived for those eligible PCP-ordered services. Claims submissions must include the ordering/referring provider; when the billed service is not rendered by the PCP, the claim must include modifier 'V1' to allow for payment.
- Prior authorizations will be waived for eligible primary care providers who order a qualifying service for a qualifying member.
- Eligible PCP must be enrolled, credentialed, and contracted with Neighborhood and be the member's assigned PCP or at the same site (referral circle) and have engaged in clinical decision making for the ordered service.
- Claims must include the ordering/referring provider; use modifier 'V1' when the billed service is not rendered by the PCP.
Pharmacy and prescription products excluded from waiver
Pharmacy products and prescription medications are excluded from the statutory waiver and continue to require prior authorization.
- Examples include diabetic testing supplies, OTC products, and prescription medications.
- Prior authorization for these products will continue to be required per the legislation.
PA waiver limited to in‑network services
The PA waiver applies only to in‑network services; out‑of‑network services require prior authorization to assess coverage and patient financial responsibility under the HHS No Surprises Act.
- When services are to be provided by an out‑of‑network provider or facility, prior authorization remains necessary.
Fraud/waste/abuse exception — PA may still be required
Providers with a documented history of fraud, waste, or abuse may be excepted from the waiver and still be required to submit prior authorization requests.
- Exception applies to individual providers with documented history, per the Rhode Island Attorney General's Office.
Non‑covered or excluded PCP‑ordered services may be denied
If a PCP orders a service that is not covered under the member's benefits or is explicitly excluded (including quantity limits), the claim will be denied or payment will be subject to the member's benefit limits.
- Services or treatments not included within a member's benefits or excluded by regulation will trigger a denial of payment.
- Quantity limits on services or products are included in excluded outcomes.
Key Terms and Billing Identifiers
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