Prior authorization decision timeframes and expedited request criteria
This document governs Neighborhood Health Plan of Rhode Island's timeframes for responding to prior authorization requests and defines clinical criteria for when an expedited prior authorization is appropriate; it affects providers submitting authorizations for NHP members.
No material clinical or coverage changes in this revision.
Expedited Prior Authorization Criteria
Expedited request criteria
Expedited prior authorization is appropriate when one or more of the following clinical rationales apply:
ONE of
- Processing the request within the standard timeframe will jeopardize the life or health of the member.
- Processing within the standard timeframe will impact the member's ability to achieve or regain maximum function.
- Processing within the standard timeframe will cause a barrier to transition of care.
Response Timeframes & Codes
| No codes listed |
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