CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Temporary Prior Authorization Waiver for Pandemic Response

Governs temporary removal of certain prior authorization requirements for Neighborhood Health Plan of Rhode Island members and providers during a state-declared pandemic emergency or when Neighborhood elects to enact the policy; applies to participating and non-participating providers across specified lines of business.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyTemporary Prior Authorization Waiver for Pandemic Response

Policy CodePolicy N/A

Change TypeMaterial revisions and additions

Effective DateN/A

Next Review DateN/A

Key ActionProviders must notify Neighborhood for all admissions and transfers while specified prior authorizations are temporarily removed.

SourceLink

POLICY UPDATE CHANGES

Extended policy effective date in accordance with Executive Order and OHIC bulletin issued July 1, 2020.

Clarified prior authorization removal for non-pharmacy COVID-19 related diagnostic and treatment services effective July 1, 2020.

Specified that prior authorizations will not be required for inpatient acute care, SNF, inpatient rehabilitation and long term care for admissions between April 1, 2020 and June 30, 2020.

Apr 1–Jun 30, 2020Date range for waived PAs for specified medical inpatient/long-term levels

Jul 1, 2020Effective date for waiver for non-pharmacy COVID-19 services

90Claim submission timeframe (days)

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Coverage Criteria and Waivers

inv-01: Medical inpatient/long-term care PA waiver (Apr 1–Jun 30, 2020)

Medical services with waived prior authorization during specified dates:

ALL of the following

ONE OF
- Inpatient Acute Care level of care determinations
- Skilled Nursing Facilities
- Inpatient Rehabilitation
- Long Term Care Facilities
Admission date (including transfer date) must occur within April 1, 2020 thru June 30, 2020
Notification to Neighborhood required for all admissions and transfers
Neighborhood reserves the right to perform retrospective and concurrent reviews
Outpatient and pharmacy authorization processes remain in effect

ALL of the following

Neighborhood's standard reimbursement rules apply to services referenced in this policy

inv-02: COVID-19 diagnostic and treatment services PA waiver (effective Jul 1, 2020)

Medical services effective July 1, 2020 with waived prior authorization:

ALL of the following

Non-pharmacy COVID-19 related diagnostic and treatment services
Services must occur within the effective date of this policy (on or after July 1, 2020)
Neighborhood's standard reimbursement rules apply
Neighborhood reserves the right to perform retrospective reviews and concurrent reviews

inv-03: Behavioral Health PA waiver

Behavioral Health:

ALL of the following

ONE OF
- Inpatient behavioral health
- Outpatient behavioral health
Prior authorizations not required when admission date (including transfer date) occurs within the policy effective dates
Neighborhood's vendor requires notification for all admissions and transfers
Neighborhood reserves the right to perform retrospective and concurrent reviews

inv-04: Exclusions and continuing requirements

Areas where authorizations or processes remain in effect:

ALL of the following

Outpatient and pharmacy authorization processes remain in effect
Standard reimbursement and contractual rules apply
Claims are subject to member eligibility, contractual edits, documentation requirements, and may be audited retrospectively
Providers must submit complete claims for payment within 90 days of the date of service
Coding must meet AMA CPT, ICD-10-CM, and HCPCS Level II standards

Coding and Claim Timing

Coding standardsmixed

CPT/ICD-10/HCPCS

Coding must meet AMA CPT, ICD-10-CM, and HCPCS Level II standards

Claim submission timeframe

Claim submission timeframeProviders must submit complete claims for payment within 90 days of the date services are provided to members.

Adjustments and correctionsAdjustments, corrections, and reconsiderations must include the required forms.

Compliance standardsAll submissions must comply with National Claims Standards.

Provider Actions and Notification Requirements

Prior Authorization

Temporary prior authorization removal and notification requirement — Neighborhood may temporarily remove prior authorization requirements for certain services during a state-declared pandemic emergency or when Neighborhood elects to enact the policy; notification/process obligations

In the event the State of Rhode Island declares a state of emergency due to a pandemic (e.g., COVID-19) or Neighborhood Health Plan of Rhode Island (Neighborhood) elects to enact this policy, Neighborhood may temporarily remove certain prior authorization requirements. This does not replace Neighborhood's Clinical Medical Policies or other Billing and Payment Policies; all other policies (including retroactive authorization, readmission, and provider preventable condition policies) remain in effect. Neighborhood may perform retrospective claims audits and request medical records.

Temporary PA removals apply only for services and dates specified in the policy effective dates.
Neighborhood may rescind or limit the temporary PA removals at its discretion and will follow state-issued timelines when applicable.

Note

Behavioral health PA waiver and notification — Behavioral Health prior authorizations will not be required for inpatient and outpatient services within the policy effective dates; vendor/provider notification details

Definitions and Scope

Temporary PA Waiver

DefinitionTemporary PA Waiver: Neighborhood may temporarily remove certain prior authorization requirements during a state-declared pandemic emergency or when Neighborhood elects to enact this policy.

Notification and reviewsNotification is required for admissions and transfers; Neighborhood reserves the right to perform retrospective and concurrent reviews.

Policy relationshipThis policy is separate from Neighborhood's Clinical Medical Policies and Billing/Payment Policies; other policies (e.g., retroactive authorization, readmission) remain in effect.

Scope

Lines of business coveredApplies to Medicaid (excluding Extended Family Planning - EFP), Commercial, and INTEGRITY lines of business.

Provider applicability