CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Adult Day – Enhanced

This document is the prior authorization form and submission instructions for Neighborhood Health Plan of Rhode Island's Adult Day Health - Enhanced services. It collects member, facility, requested service, attendance, clinical information, and documents required to support an initial or continuation authorization request.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyAdult Day – Enhanced

Policy CodePolicy N/A

Change TypeInformational (no material change)

Effective Date

Next Review Date

Key ActionReturn the completed Adult Day Health - Enhanced Services Prior Authorization Form with all required clinical documentation to Utilization Management at fax (401) 459-6023 to avoid processing delays.

SourceLink

POLICY UPDATE CHANGES

No material changes: This update does not introduce any material clinical or coverage changes.

1Form Type (Authorization Form)

5Required Clinical Interventions

5Required Documentation Items

Policy overview & purpose

This is the Adult Day Health - Enhanced prior authorization form and submission instructions for Neighborhood Health Plan of Rhode Island. It operationalizes prior authorization for enhanced adult day health services and collects member, facility, requested service, attendance schedule, clinical information, and required supporting documents to support an initial or continuation authorization request.

Authorization request types

Authorization Request Types

Select the type of request being submitted:

Initial Request
Continuation of Services

Authorization Request Types (duplicate)

Required Clinical Interventions (check all that apply)

Authorization should include documentation that one or more of the following interventions are provided as part of the member's plan of care:

Required Clinical Interventions

Two ADLs: Daily assistance on site in the center, with at least two (2) Activities of Daily Living (ADL).
Skilled nursing service: Daily assistance on site in the center, with at least one skilled service, by a Registered Professional Nurse (RN) or a Licensed Practical Nurse (LPN).
Two-person assist ADL: Daily assistance on site in the center, with at least one (1) Activities of Daily Living (ADL) which requires a two-person assist to complete the ADL.
Three ADLs with supervision/cueing: Daily assistance on site in the center; with at least three (3) Activities of Daily Living (ADL) when supervision and cueing are needed to complete the ADL's identified.
Dementia/behavioral safety risk: An individual who has been diagnosed with Alzheimer's disease or other related dementia, or a mental health diagnosis, as determined by a physician, requires regular staff interventions due to safety concerns related to elopement risk or other behaviors and inappropriate behaviors that adversely impact themselves or others. Such behaviors and interventions must be documented in the participant's care plan and in the required progress notes.

Required Clinical Interventions (duplicate)

Documentation Requirements

Requests must include relevant clinical documentation:

Physician office notes
Adult day admission assessment and plan of care
Quarterly plan of care reviews
Adult day progress notes
Patient's clinical information

Documentation Requirements (duplicate)

What providers must do

Prior Authorization

Submit completed prior authorization form

Return the completed Adult Day Health - Enhanced Services Prior Authorization Form to Utilization Management at fax (401) 459-6023. Include all required clinical documentation to avoid processing delays.

Documentation Required

Required supporting documentation

Attach physician office notes, adult day admission assessment and plan of care, quarterly plan of care reviews, adult day progress notes, and other patient clinical information. Insufficient information will delay processing.

Billing Rule

Authorization is not a guarantee of payment

Authorization is not a guarantee of payment. If authorized, include the authorization number and the approved dates/services on claims as applicable.

Denial Risk

Incomplete submissions risk denial/delay

Requests submitted without sufficient information will delay processing and may result in a Not Approved determination documented by a follow-up letter.