CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Temporary Prior Authorization Policy during pandemic state of emergency

Governs temporary removal of certain prior authorization requirements for Neighborhood Health Plan of Rhode Island providers during a declared state of emergency (or when Neighborhood elects to enact it). Affects participating and non-participating providers across most lines of business (excluding Medicaid Extended Family Planning).

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyTemporary Prior Authorization Policy during pandemic state of emergency

Policy CodePolicy N/A

Change TypeExtended effective datestemporary waivers

Effective DateApr 1, 2020

Next Review DateN/A

Key ActionProviders must notify Neighborhood (or vendor) for all admissions and transfers even when prior authorization is temporarily waived.

SourceLink

POLICY UPDATE CHANGES

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

Extended policy effective date in accordance with Executive Order and OHIC Bulletin issued April 27, 2020.

Policy effective April 1, 2020 removing certain prior authorizations for specified services during the effective period.

07/13/20most recent update

90 daysclaims submission window

Apr 1 - Jun 30, 2020initial medical effective period

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Services Temporarily Waived from Prior Authorization

Services with prior authorization temporarily waived

Prior authorizations temporarily not required during effective periods for specified services:

Medical (Apr 1–Jun 30, 2020)

ANY of the following
- Inpatient Acute Care level of care determinations (admission or transfer date within the effective period)
- Skilled Nursing Facilities (admission or transfer date within the effective period)
- Inpatient Rehabilitation (admission or transfer date within the effective period)
- Long Term Care Facilities (admission or transfer date within the effective period)
Notification to Neighborhood required for all admissions and transfers; Neighborhood reserves the right to perform retrospective and concurrent reviews.

Medical (effective Jul 1, 2020)

ANY of the following
- Non-pharmacy COVID-19 related diagnostic and treatment services that occur within the effective period
Outpatient and pharmacy authorization processes remain in effect.

Behavioral Health (during effective period)

ANY of the following
- Inpatient behavioral health admissions (admission or transfer date within the effective period)
- Outpatient behavioral health services (admission or transfer date within the effective period)
Vendor notification required for all behavioral health admissions and transfers; Neighborhood reserves the right to perform retrospective and concurrent reviews.

Coding and Claims Timeliness

Referenced coding systemsmixed

CPT, ICD-10-CM, HCPCS

Coding systems referenced for claims and coding standards

Claims submission timeliness

Timeliness requirementProviders 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.

Standards complianceAll submissions must comply with National Claims Standards.

Referenced coding systems for claimsClaims must meet standards defined by CPT, ICD-10-CM, and HCPCS Level II coding systems.

Contractual applicabilityBillable services are subject to applicable contractual agreements.

Provider Notification, Review, and Ongoing Authorization Rules

Prior Authorization

Temporary removal of prior authorization; notification and review requirements

Neighborhood may temporarily remove prior authorization requirements for certain services during a declared state of emergency or when Neighborhood elects to enact this policy. Providers must still notify Neighborhood for all admissions and transfers; Neighborhood reserves the right to perform retrospective and concurrent reviews and audits of records and claims.

Notification is required for all admissions and transfers.
Neighborhood reserves the right to perform retrospective reviews, concurrent reviews, and claims payment audits.

Note

Outpatient and Pharmacy; Behavioral Health

Outpatient and pharmacy authorization processes remain in effect and must continue to be followed. Behavioral health prior authorizations for inpatient and outpatient admissions are not required during the policy effective period, but the vendor requires notification for all admissions and transfers and Neighborhood may perform retrospective and concurrent reviews.

Scope and Key Definitions

State of emergency

State of emergency definitionPolicy enacted in the event the State of Rhode Island declares a state of emergency due to a pandemic health concern (e.g., COVID-19), or when Neighborhood elects to enact this policy outside a declared emergency.

Scope of applicabilityApplies to Neighborhood participating and non‑participating providers across all lines of business except Medicaid Extended Family Planning (EFP).

Policy duration guidancePolicy remains in effect through the earlier of October 1, 2020 (unless OHIC or Executive Order extends/shortens it) or the expiration of the Executive Order (per policy history).

Continuing policiesOther Neighborhood clinical, medical, and payment policies (e.g., retroactive authorization, readmission, provider preventable condition policies) continue to apply while this temporary policy is in effect.

Scope