CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Temporary Prior Authorization Policy (Pandemic / Emergency Waivers)

Defines temporary suspension or modification of certain prior authorization requirements for members during a declared state of emergency or when enacted by the payer; applies to Medicaid (excl. EFP), INTEGRITY, and Commercial lines and participating providers.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyTemporary Prior Authorization Policy (Pandemic / Emergency Waivers)

Policy CodePolicy N/A

Change TypeOperational clarifications and date-range updates

Effective DateApr 1, 2020

Next Review DateN/A

Key ActionNotify Neighborhood for all admissions and transfers; prior authorizations may be temporarily waived during declared emergencies while pharmacy authorizations remain required.

SourceLink

POLICY UPDATE CHANGES

Policy implementation, modification, and termination will be communicated via Neighborhood's COVID-19 Provider Guidance website and may be enacted without the normal sixty day provider notification.

Effective date windows and service categories for which prior authorizations are waived were updated multiple times to reflect Executive Orders and state bulletins (examples: windows through June 30, 2020; July 1, 2020; December 1, 2020; and extended through March 17, 2021 per RI Executive Order).

3service categories with PAs waived in Apr–Jun 2020

non-pharmacynon-pharmacy COVID-19 services exempted (Jul 1, 2020+)

Behavioral Health

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Temporary Prior Authorization Waivers — Coverage Criteria

inv-01: Apr 1, 2020 – Jun 30, 2020 waivers

Prior authorizations will not be required for the following services when the admission date (including transfer date) occurs within the effective date of this policy (April 1, 2020 through June 30, 2020):

Inpatient Acute Care level of care determinations

Skilled Nursing Facilities

Inpatient Rehabilitation

Long Term Care Facilities

Notification to Neighborhood is required for all admissions and transfers; Neighborhood reserves the right to perform retrospective and concurrent reviews

Outpatient and Pharmacy Authorization processes remain in effect.

inv-02: July 1, 2020 and later waivers

Prior authorizations will not be required for the following services that occur within the effective dates specified (effective July 1, 2020 and later windows):

Non-pharmacy COVID-19 related diagnostic and treatment services

In-patient COVID-19 related treatment in out-of-network facilities

Applies to specified windows e.g., December 1, 2020 through the earlier of March 17, 2021 or expiration of the Executive Order.

Notification to Neighborhood is required for all admissions and transfers; Neighborhood reserves the right to perform retrospective and concurrent reviews

Pharmacy Authorization processes remain in effect.

inv-03: Behavioral Health waivers

Behavioral health prior authorizations will not be required for services occurring within the effective dates indicated:

Behavioral Health Inpatient Services (PA waived for specified date ranges)

Behavioral Health Outpatient Services (PA waived for specified date ranges)

Behavioral health vendor requires notification for all admissions and transfers; providers should contact OPTUM Provider Express for the most current information

Neighborhood reserves the right to perform retrospective and concurrent reviews.

inv-04: Exceptions and requirements

Exceptions and continuing requirements (these requirements remain in effect even when prior authorizations are waived):

Pharmacy authorizations remain required

Outpatient services generally remain subject to authorization unless specifically listed as waived

Notification to Neighborhood is required for all admissions and transfers; Neighborhood may perform retrospective and concurrent reviews

Required Coding Systems

Provider Notifications, Claims, and Operational Rules

Prior Authorization

Temporary removal of PA requirements during declared emergency

Neighborhood may temporarily remove certain prior authorization requirements during a declared state of emergency or when Neighborhood elects to enact this policy. This temporary removal does not affect other Neighborhood Clinical Medical Policies, Billing and Payment Policies, retroactive authorization, readmission policies, or provider preventable condition policies.

Documentation Required

Admission and transfer notification; retrospective/concurrent review

Providers must notify Neighborhood of all admissions and transfers. Neighborhood reserves the right to perform retrospective and concurrent reviews related to those admissions/transfers.

Scope and Medical Necessity Definitions

Medical necessity

DefinitionAll services must be medically necessary to qualify for reimbursement; Neighborhood may use NCDs, LCDs, Interqual, EOHHS recommendations, and Clinical Medical Policies to determine medical necessity.

ResponsibilityIt is the provider's responsibility to verify eligibility, coverage and authorization criteria prior to rendering services.

Relation to other policiesThis temporary prior authorization policy is separate from Neighborhood's Clinical Medical Policies and other Billing and Payment Policies; other policies (e.g., retroactive authorization, readmission, provider preventable condition policies) remain in effect.

Contact for questionsProviders should contact Provider Services at 1-800-963-1001 for questions related to this policy.

Scope

Lines of business covered