Non-Surgical Interventional Pain Management Prior Authorization Form
This document is a prior authorization request form governing non-surgical interventional pain management procedures for Neighborhood Health Plan of Rhode Island members; it affects ordering providers who must submit clinical information to Utilization Management for authorization decisions.
No material clinical or coverage changes in this revision.
Authorization & Documentation Requirements
Authorization Submission and Documentation Requirements
Authorization requires completion of the prior authorization form and submission of specified clinical documentation; Utilization Management will document the decision (approval or denial) and authorization details.
ALL of the following
- Completed prior authorization form returned to the Utilization Management Department (phone/fax as indicated).
- Form must be signed by treating physician.
- Attach clinical notes that include ALL of the following: last injection/injection history; relief from last injection; provocative testing results; previous physical therapy; pain medications used; functional impairment; and a comprehensive pain management treatment plan.
- Specify requested procedure with CPT code(s), units, levels, anatomic location, laterality (bilateral/unilateral, left/right), and anesthesia type (local or MAC).
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