CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Temporary Prior Authorization Waiver for COVID-19 / Pandemic

Governs temporary removal of certain prior authorization requirements for Neighborhood Health Plan of Rhode Island members during a declared state of emergency for a pandemic (e.g., COVID-19) or when Neighborhood elects to enact the policy; affects providers and commercial members (excluding Extended Family Planning).

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyTemporary Prior Authorization Waiver for COVID-19 / Pandemic

Policy CodePolicy N/A

Change TypeMultiple date extensionsreinstatements and clarifications

Effective Date

Next Review Date

Key ActionTemporarily remove certain prior authorization requirements for specified services during a declared state of emergency or when Neighborhood elects to enact this policy.

SourceLink

POLICY UPDATE CHANGES

Reinstated suspension of authorization requirements on all inpatient services effective 12/1/20 to 2/28/21 (or termination of the Executive Order) for Commercial Members.

Medicaid/MMP authorization requirement to be waived for COVID diagnosis only.

Extended and updated effective dates of temporary waiver periods in alignment with Executive Orders and OHIC/EOHHS bulletins (multiple date extensions noted).

4types of inpatient/long-term settings listed as waived

Multiplepolicy effective windows documented

Pharmacy

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Temporary Prior Authorization Coverage Criteria

Prior authorization requirements are temporarily waived for specified services when admission or service dates fall within the policy effective periods; pharmacy authorizations remain in effect and notification and retrospective/concurrent review requirements persist.

ALL of the following

ANY of the following
- Inpatient Acute Care level of care determinations
- Inpatient Rehabilitation
- Skilled Nursing Facilities
- Long Term Care Facilities
ALL of the following
- Neighborhood requires notification for all admissions and transfers
- Neighborhood reserves the right to perform retrospective and concurrent reviews

ALL of the following

Prior authorizations will not be required for non-pharmacy COVID-19 related diagnostic and treatment services when the service date occurs within the policy effective period
Pharmacy authorization processes remain in effect
Where applicable, in-patient COVID-19 related treatment in out-of-network facilities is included during certain effective windows (see policy effective dates)
Neighborhood requires notification for admissions and transfers and reserves the right to retrospective and concurrent reviews

ALL of the following

ANY of the following
- Inpatient behavioral health services
- Outpatient behavioral health services
- Non-pharmacy COVID-19 related diagnostic and treatment services for behavioral health during specified effective periods
ALL of the following
- Neighborhood's behavioral health vendor requires notification for all admissions and transfers
- Neighborhood reserves the right to perform retrospective and concurrent reviews

ALL of the following

All services provided under these temporary waivers must meet medical necessity criteria; Neighborhood may reference LCDs, NCDs, InterQual, EOHHS recommendations, and Clinical Medical Policies
Neighborhood may audit medical records and perform retrospective/concurrent review despite temporary waivers

Applicable Coding and Filing Rules

Required coding systemsmixed

CPT	Coding must meet standards defined by AMA CPT codebook
ICD-10-CM	Diagnosis coding per ICD-10-CM
HCPCS	Procedure/Item codes per HCPCS Level II

Timely filing

Timely filing requirementProviders must submit complete claims for payment within contractually determined timely guidelines.

Applicable submissionsAdjustments, corrections, and reconsiderations must include required forms and comply with National Claims Standards.

Governing bulletinHealth Insurance Bulletin 2020-08 (Issued Nov 24, 2020; Effective Dec 1, 2020) referenced for claims guidance.

Provider Responsibilities and Authorization Waivers

Prior Authorization

Temporary Prior Authorization Waiver

When the State of Rhode Island declares a state of emergency for a pandemic (e.g., COVID-19), or when Neighborhood elects to enact this policy outside a declared emergency, Neighborhood may temporarily remove certain prior authorization requirements for specified services.

Prior Authorization

Inpatient and Long‑Term Care Waivers

Prior authorizations will not be required for inpatient acute care level of care determinations, inpatient rehabilitation, skilled nursing facility stays, and long term care facility admissions when the admission (including transfer) date falls within the policy effective period; however, notification for all admissions and transfers is still required.

Prior Authorization

COVID‑19 Diagnostic/Treatment Waiver (Non‑Pharmacy)

Prior authorizations will not be required for non‑pharmacy COVID‑19 diagnostic and treatment services occurring within the policy effective dates (effective July 1, 2020 for medical services and included in other effective windows); pharmacy authorizations remain in effect.

Key Definitions

Prior Authorization Waiver

Prior Authorization WaiverTemporary waiver of certain prior authorization requirements applied during a declared state of emergency (e.g., pandemic) or when Neighborhood elects to enact this policy.

ScopeApplies to Neighborhood members excluding Extended Family Planning (EFP); Neighborhood may implement, modify, or terminate the policy and will notify providers via the COVID-19 Provider Guidance website.

Relation to other policiesThis policy is separate from Neighborhood's Clinical Medical Policies and Payment Policies; other policies (e.g., retroactive authorization, readmission) continue to apply.

Medical Necessity

DefinitionServices that meet criteria such as Local Coverage Determination (LCD), National Coverage Determination (NCD), InterQual, EOHHS recommendations, or Clinical Medical Policies (CMP).