CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Adult Health-Enhanced Services Prior Authorization Form

Form and process for requesting prior authorization of adult health-enhanced services; applies to providers submitting authorization requests for skilled and non-skilled services for adult members.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyAdult Health-Enhanced Services Prior Authorization Form

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionComplete and return the Adult Health-Enhanced Services Prior Authorization Form to the Utilization Management Department (phone (401)459-6023) with member/provider info, dates of service, diagnosis and procedure codes, clinical information and requested services.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1 pageform length

phone: (401)459-6023UM contact

1+ skilledskilled service

≥2 ADLsnon-skilled ADL

physician requiredsignature

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Authorization Criteria

Requested services must be supported by clinical information and meet the form's stated criteria:

ALL of the following

Skilled service
- At least one skilled service provided by a Registered Professional Nurse (RN) or a Licensed Practical Nurse (LPN)
Non‑skilled care ADL threshold
- At least two (2) Activities of Daily Living (ADL) for non‑skilled care
- At least one (1) ADL requiring a two‑person assist to complete
- At least three (3) ADLs when supervision and cueing are needed to complete the ADLs
Behavioral / dementia care documentation
- Individual diagnosed with Alzheimer’s disease, related dementia, or a mental health diagnosis requiring regular staff interventions for safety (e.g., elopement risk) or other behaviors that adversely impact the individual or others
- Such behaviors and interventions are documented in the participant’s care plan and in required progress notes
Diagnosis and procedure codes are provided on the form and clinical information (Diagnosis & Diagnosis Code; Procedure & Procedure Code)

Diagnosis and Service Codes / ADL Thresholds

Requested diagnosis/procedure codesmixed

Diagnosis & Procedure code fields are requested on the form; specific codes must be provided by the ordering/provider.

Non-skilled ADL threshold

Non-skilled ADL thresholdAt least two (2) Activities of Daily Living (ADL)

Two-person assistAt least one (1) ADL which requires a two-person assist to complete the ADL

Supervision/cueing thresholdAt least three (3) Activities of Daily Living when supervision and cueing are needed to complete the ADLs

Prior Authorization Submission Instructions

Prior Authorization

Prior Authorization Submission: Submit completed form to Utilization Management

Complete and return the Adult Health-Enhanced Services Prior Authorization Form to the Utilization Management Department. Include member and provider information, date(s) of service, diagnosis and procedure codes, clinical information, and requested services. If requesting skilled services, the form requires a physician or licensed provider signature.

Return completed form to the Utilization Management Department at (401)459-6023.
Provide member and provider information, date(s) of service, diagnosis and procedure codes, clinical information, and requested services on the form.
If requesting at least one skilled service, obtain signature of a physician or licensed provider on the form.

Service Definitions

Non-Skilled Care

DefinitionNon-Skilled Care: services requested based on provider evaluation and assessment under the Non-Skilled Care section of the form

Minimum ADL requirementAt least two (2) Activities of Daily Living (ADL)

Behavioral/dementia considerationIndividuals with Alzheimer’s, related dementia, or a mental health diagnosis requiring regular staff interventions for safety/behavioral concerns must have such behaviors and interventions documented in the participant’s care plan and required progress notes

Skilled Service

Skilled service requirementAt least one skilled service provided by a Registered Professional Nurse (RN) or a Licensed Practical Nurse (LPN)

Form placement