CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Temporary Prior Authorization Policy

Temporary removal of certain prior authorization requirements for Neighborhood members and providers during a declared state of emergency for a pandemic (e.g., COVID-19), and when Neighborhood elects to enact the policy outside a declared emergency; applies to participating and non-participating providers across lines of business including Medicaid (excluding EFP), Commercial, and INTEGRITY.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyTemporary Prior Authorization Policy

Policy CodePolicy N/A

Change TypeClarification & Revised effective dates

Effective DateApr 1, 2020

Next Review DateN/A

Key ActionDo not submit prior authorization requests for qualifying inpatient, behavioral health, and non-pharmacy COVID-19 services occurring within the policy effective periods; notify Neighborhood of admissions and transfers as required.

SourceLink

POLICY UPDATE CHANGES

Language regarding implementation, modification, and termination of policy added.

Policy effective dates were extended in accordance with Executive Order and OHIC bulletins.

Apr 1–Jun 30, 2020Inpatient prior auth waiver period

Effective Jul 1, 2020Non-pharmacy COVID-19 waiver start

90 daysClaim submission window

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Medicaid, Commercial, INTEGRITY

Lines of business covered

Temporary Prior Authorization Coverage Criteria

Temporary prior authorization coverage criteria

During the policy effective periods, Neighborhood waives prior authorization requirements for specified services; providers must notify Neighborhood of admissions/transfers and Neighborhood may perform retrospective or concurrent review.

Waiver applies only when the admission date (including transfer date) occurs within the policy effective period.

Inpatient levels waiver (Apr 1–Jun 30, 2020)

Prior authorizations not required for Inpatient Acute Care level of care determinations when admission/transfer date is within Apr 1–Jun 30, 2020.
Prior authorizations not required for Skilled Nursing Facility admissions when admission/transfer date is within Apr 1–Jun 30, 2020.
Prior authorizations not required for Inpatient Rehabilitation admissions when admission/transfer date is within Apr 1–Jun 30, 2020.
Prior authorizations not required for Long Term Care Facility admissions when admission/transfer date is within Apr 1–Jun 30, 2020.

Provider notification and review

Neighborhood requires notification for all admissions and transfers (including those covered by the temporary waivers).
Neighborhood reserves the right to perform retrospective reviews and concurrent reviews for cases under the waiver.

COVID-19 non-pharmacy services waiver (effective Jul 1, 2020)

Prior authorizations not required for non-pharmacy COVID-19 related diagnostic and treatment services that occur on or after July 1, 2020 within the policy effective period.
Standard outpatient and pharmacy authorization processes remain in effect (i.e., outpatient and pharmacy services are not waived by this policy).

Behavioral health waiver

Prior authorizations not required for inpatient behavioral health services when admission/transfer date is within the policy effective period.
Prior authorizations not required for outpatient behavioral health services when admission/transfer date is within the policy effective period.
Neighborhood's behavioral health vendor requires notification for all admissions and transfers; Neighborhood reserves the right to perform retrospective or concurrent reviews.

Coding, Claims Standards, and Submission Windows

Coding and claims standardsmixed

References to CPT and HCPCS are for definitional purposes; claims must meet AMA CPT and HCPCS standards and National Claims Standards.

Claim submission window

Claim submission windowProviders must submit complete claims for payment within 90 days of the date services are provided to members; adjustments, corrections, and reconsiderations must include required forms and comply with National Claims Standards.

Standards referencedClaims must meet AMA CPT and HCPCS Level II (HCPCS) standards as applicable.

Scope of billable servicesBillable services are subject to contractual agreements when applicable.

Provider Actions and Operational Waivers

Prior Authorization

Temporary waiver — select inpatient prior authorizations (Apr 1–Jun 30, 2020)

Temporary waiver for select inpatient prior authorizations is in effect for admissions (including transfers) with dates from April 1, 2020 through June 30, 2020. Providers must still notify Neighborhood for all admissions and transfers; Neighborhood may perform concurrent or retrospective reviews. Outpatient and pharmacy authorization processes remain in effect.

Effective period: April 1, 2020 – June 30, 2020
Affected levels: Inpatient acute care level of care determinations; Skilled nursing facilities; Inpatient rehabilitation; Long term care facilities
Notification required: Providers must notify Neighborhood for all admissions and transfers
Review rights: Neighborhood reserves the right to perform retrospective and concurrent reviews

Prior Authorization

Temporary waiver — non-pharmacy COVID-19 services (effective Jul 1, 2020)

Temporary waiver for non-pharmacy COVID-19 diagnostic and treatment services effective July 1, 2020. Prior authorization will not be required for covered non-pharmacy services related to COVID-19 that occur on or after this date. Providers should continue to follow normal billing and documentation requirements and submit notifications per usual processes where required.

Scope and Definitions

Temporary Prior Authorization Policy

Policy labelTemporary Prior Authorization Policy — temporary removal of certain authorization requirements during a pandemic or when Neighborhood elects to enact this policy outside a declared state of emergency.

Relationship to other policiesThis policy is separate from Neighborhood's Clinical Medical Policies and Payment Policies, which remain in effect.

Implementation authorityNeighborhood may implement, modify, or terminate this temporary policy and will communicate changes via its COVID-19 Provider Guidance website.

Scope (lines of business)

Covered lines of businessMedicaid (excluding Extended Family Planning / EFP)

Covered lines of businessCommercial

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyTemporary Prior Authorization Policy

Policy CodePolicy N/A

Change TypeClarification & Revised effective dates

Effective DateApr 1, 2020

Next Review DateN/A

SourceLink

On This Page

Effective date: July 1, 2020 (onward)
Scope: Non-pharmacy COVID-19 related diagnostic and treatment services
Note: Pharmacy prior authorization processes remain separate and are not waived here

Prior Authorization

Behavioral health prior authorization waiver

Behavioral health inpatient and outpatient prior authorizations are temporarily waived for admissions (including transfers) occurring within the policy effective dates. Neighborhood’s vendor requires notification for all behavioral health admissions and transfers. Neighborhood reserves the right to perform concurrent and retrospective reviews.

Applies to: Inpatient and outpatient behavioral health services
Notification required: Behavioral health vendor (QPTUM Provider_Express) requires notification for all admissions and transfers
Review rights: Neighborhood reserves the right to perform retrospective and concurrent reviews

Note

Implementation, modification, termination and remaining authorizations

Neighborhood may implement, modify, or terminate this temporary prior authorization policy at its discretion and will communicate changes via the Neighborhood COVID-19 Provider Guidance website. Previously authorized services remain subject to Neighborhood policies; Neighborhood will continue to apply other clinical and payment policies (including retroactive authorization, readmission, and provider preventable condition billing policies).

Neighborhood reserves the right to implement/modify/terminate this temporary policy without normal contractual notification
Notifications of changes will be posted on Neighborhood’s COVID-19 Provider Guidance website
Other policies remain in effect: retroactive authorization, readmission policies, provider preventable condition billing policies

Covered lines of businessINTEGRITY