CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Temporary Prior Authorization Suspension During Pandemic or Emergency

Governs temporary suspension of certain prior authorization requirements for Neighborhood Health Plan of Rhode Island members and providers (participating and non-participating) during a state-declared pandemic emergency or when Neighborhood elects to enact this policy outside a declared emergency.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyTemporary Prior Authorization Suspension During Pandemic or Emergency

Policy CodePolicy N/A

Change TypeExtension of effective date (no material clinical changes)

Effective DateN/A

Next Review DateN/A

Key ActionDo not submit prior authorization requests for specified inpatient, long-term care, and behavioral health admissions that occur during the policy effective period; notify Neighborhood (or vendor) of all admissions and transfers.

SourceLink

POLICY UPDATE CHANGES

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

90 daystimeframe for providers to submit complete claims

Medicaid, Commercial, INTEGRITYlines of business covered

Inpatient/SNF/Rehab/LTCmedical settings exempt

Inpatient & Outpatient

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Services Temporarily Not Requiring Prior Authorization

inv-01: Medical inpatient and long-term care waiver

Medical services for which prior authorization is temporarily not required if admission/transfer date falls within the policy effective period:

Inpatient Acute Care level of care determinations

Skilled Nursing Facilities

Inpatient Rehabilitation

Long Term Care Facilities

inv-02: Behavioral health waiver

Behavioral health services for which prior authorization is temporarily not required if admission/transfer date falls within the policy effective period:

Behavioral Health Inpatient services

Behavioral Health Outpatient services

inv-03: Ongoing authorization and audit requirements

Exceptions and ongoing requirements:

Outpatient and Pharmacy Authorization processes remain in effect

These authorizations continue to be required during the policy effective period.

Notification to Neighborhood (or vendor) required for all admissions and transfers

Providers must notify Neighborhood; Behavioral Health vendor (Optum Provider Express) requires notification for admissions/transfers.

Neighborhood reserves the right to perform retrospective and concurrent reviews and audits

Neighborhood may conduct retrospective and concurrent reviews despite temporary suspension of prior authorization for specified services.

Coding and Claim Submission Requirements

Required coding standardsmixed

CPT, ICD-10-CM, HCPCS

Coding must meet standards defined by CPT, ICD-10-CM, and HCPCS Level II.

Claim submission timeframe

Required claim filing 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 standardAll submissions must comply with National Claims Standards.

Provider Notification and Authorization Actions

Prior Authorization

Temporary suspension of prior authorization for specified medical inpatient settings — provider actions

Do not submit prior authorization requests for inpatient acute care, skilled nursing facility, inpatient rehabilitation, or long‑term care admissions when the admission or transfer date falls within the policy effective period. However, notify Neighborhood of all admissions and transfers; Neighborhood may perform retrospective or concurrent reviews.

Prior authorizations not required for: Inpatient Acute Care level of care determinations, Skilled Nursing Facilities, Inpatient Rehabilitation, Long Term Care Facilities when admission/transfer date is within the policy period.
Notification to Neighborhood required for all admissions and transfers.
Neighborhood reserves the right to perform retrospective and concurrent reviews.

Prior Authorization

Temporary suspension of prior authorization for behavioral health — provider actions

Do not submit prior authorization requests for behavioral health inpatient or outpatient services when the admission or transfer date falls within the policy effective period. Ensure OPTUM (Neighborhood's behavioral health vendor) is notified of all admissions and transfers; Neighborhood may conduct retrospective or concurrent reviews.

Scope and Definitions

State of Rhode Island declaration of a pandemic health emergency

Trigger for policyPolicy applies when 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 the policy outside a declared emergency.

Relation to other policiesThis temporary policy is separate from Neighborhood's Clinical Medical Policies and other Billing and Payment Policies; other policies remain in effect.

Regulatory anchorsPolicy timeframe tied to Executive Order 20-29 and OHIC Bulletin 2020-03 (issued April 27, 2020).

Lines of business covered

Covered lines of businessApplies to all lines of business: Medicaid (excluding Extended Family Planning/EFP), Commercial, and INTEGRITY.

Provider applicability