CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Temporary Prior Authorization Waivers for Pandemic Emergencies

Governs temporary suspension or reinstatement of prior authorization requirements for specified services during a state of emergency (or when Neighborhood elects to enact the policy) and applies to Neighborhood Health Plan of Rhode Island lines including Medicaid (excluding EFP), INTEGRITY, and Commercial providers.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyTemporary Prior Authorization Waivers for Pandemic Emergencies

Policy CodePolicy N/A

Change TypeReinstatement & temporary waivers

Effective DateN/A

Next Review DateN/A

Key ActionNotify Neighborhood for all admissions and transfers during waiver periods; Neighborhood may perform retrospective and concurrent reviews.

SourceLink

POLICY UPDATE CHANGES

Auth rules reinstated for Medicaid and Integrity effective 10/01/21.

Specified date ranges where prior authorizations are not required for COVID-19 related services and various levels of care (multiple effective periods listed).

Policy was marked obsolete on 05/01/23 and refers providers to the prior authorization search tool.

Multiple windowsEffective periods listed for temporary waiver or reinstatement

3 product linesCovered lines

Notification requiredProvider notification requirement retained

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Temporary Prior Authorization Waiver Criteria

Temporary prior auth waiver criteria

During specified effective date windows, prior authorizations are not required for the listed services. Pharmacy authorizations and other authorization processes remain in effect; notification and retrospective/concurrent review rights are retained as indicated.

Waived non-pharmacy COVID-19 diagnostic and treatment services

Non-pharmacy primary COVID-19 related diagnostic and treatment services - prior authorization not required when service date falls within any listed effective window
Pharmacy Authorization processes remain in effect
Effective windows include: Jul 1, 2020 through Sep 30, 2021; Jul 1, 2020 through Nov 30, 2020; Jan 18, 2021 through Dec 31, 2021; Jun 10, 2021 (effective date) and other listed date ranges where specified in the policy
See specific effective period entries in source

Waived inpatient and long-term care level admissions (admission/transfer within window)

Inpatient Acute Care level of care determinations - prior authorization not required when admission/transfer date is within an effective window
Neighborhood will require notification for all admissions and transfers; Neighborhood reserves the right to perform retrospective and concurrent reviews
Skilled Nursing Facilities - prior authorization not required when admission/transfer date is within an effective window
Neighborhood will require notification for all admissions and transfers; Neighborhood reserves the right to perform retrospective and concurrent reviews
Inpatient Rehabilitation - prior authorization not required when admission/transfer date is within an effective window
Neighborhood will require notification for all admissions and transfers; Neighborhood reserves the right to perform retrospective and concurrent reviews
Long Term Care Facilities - prior authorization not required when admission/transfer date is within an effective window
Neighborhood will require notification for all admissions and transfers; Neighborhood reserves the right to perform retrospective and concurrent reviews
Inpatient and Outpatient services (as specified for Commercial/Medical services) - prior authorization not required when admission/transfer or service date is within an effective window
See specific date ranges in policy (e.g., Apr 1, 2020–Jun 30, 2020; Apr 1, 2020–Jan 17, 2021; Apr 1, 2020–Jun 9, 2021; Dec 1, 2020–Jun 9, 2021)

Behavioral health

Primary COVID-19 related behavioral health services - prior authorization not required for services occurring Jun 10, 2021 through Dec 31, 2021
Providers for behavioral health should contact OPTUM Provider Express for the most current information

General conditions and exceptions

Pharmacy authorizations remain required and are not waived under any of the effective windows listed
Notification requirement: Neighborhood (or Neighborhood's vendor) requires notification for all admissions and transfers during waiver periods
Neighborhood reserves the right to perform retrospective and concurrent reviews
Neighborhood may perform retrospective and concurrent reviews and may require records to confirm medical necessity despite temporary waiver of prior authorization

Reinstatement note

Prior authorization requirements were later reinstated for applicable services (see policy history and notices); providers should consult the prior authorization search tool or notices for current requirements

Coding and Filing Requirements

CPT CodesCPT

See AMA CPT codebook

All CPT coding must follow Current Procedural Terminology Editorial Panel guidelines; use codes that accurately describe the service provided and adhere to payer-specific billing edits and bundling rules.

HCPCS CodesHCPCS

See HCPCS Level II

Use HCPCS Level II codes for supplies, products, and services not described by CPT; follow CMS and payer-specific coding guidance.

ICD-10-CM CodesICD-10

See ICD-10-CM code set

Diagnosis coding must follow ICD-10-CM official coding guidelines and represent the member's medical condition(s) for the billed service; include appropriate sequencing and specificity.

Coding and Filing Requirements

Timely FilingProviders must submit complete claims within contractually determined timely filing guidelines; late submissions may be denied per contract.

Claim Adjustments and CorrectionsAdjustments, corrections, and reconsiderations must include required forms and documentation; follow payer procedures for resubmission.

National Claims StandardsAll submissions must comply with National Claims Standards (ASC X12, HIPAA) and any applicable state or federal requirements.

Coding StandardsCoding must meet standards defined by the AMA CPT codebook, ICD-10-CM, and HCPCS Level II; use current code editions and follow official guidance.

DocumentationMedical record documentation must support the codes submitted, including medical necessity, service details, and dates of service; retain documentation per contract requirements.

Contractual Requirements

What Providers Must Do

Prior Authorization

Temporary removal of prior authorizations

In the event of a declared state of emergency for a pandemic (e.g., COVID-19) or when Neighborhood elects to enact this policy outside of a declared emergency, Neighborhood may temporarily remove certain prior authorization requirements for specified services; specific effective date ranges in the policy list which services are waived. This temporary removal is separate from Neighborhood’s Clinical Medical Policies and other billing/payment policies.

Documentation Required

Notification and review requirements

Providers must notify Neighborhood (or Neighborhood's vendor as applicable) for all admissions and transfers that occur within the policy effective windows; Neighborhood reserves the right to perform retrospective and concurrent reviews of those admissions and transfers.

Notification required for all admissions and transfers during waiver periods.
Neighborhood reserves the right to perform retrospective and concurrent reviews.

Key Definitions

Temporary prior authorization waiver — definition

DefinitionTemporary prior authorization waiver: a temporary removal of certain prior authorization requirements during a declared state of emergency (e.g., pandemic) or when Neighborhood elects to enact this policy.

Scope of applicationApplies to Medicaid (excluding EFP), INTEGRITY, and Commercial lines unless otherwise specified.

Effective periodsSpecific services and levels of care have defined effective date windows listed in the policy during which prior authorizations are not required.

ExceptionsPharmacy authorizations and other existing policies (e.g., Clinical Medical Policies, readmission policies) remain in effect and are not waived.

Neighborhood authorityNeighborhood may implement, modify, or terminate the temporary waiver and will notify providers via its COVID-19 Provider Guidance website.