Neighborhood Clinical Medical Policies and Billing Guidelines
Describes Neighborhood Health Plan's Clinical Medical Policies (CMPs) and billing/payment policy resources, including how CMPs are developed and where to find current policies and payment guidelines. Applies to providers interacting with Neighborhood Health Plan of Rhode Island regarding prior authorization, coverage determinations, and billing.
No material clinical or coverage changes in this revision.
Coverage Criteria
A service or technology may be determined medically necessary by Neighborhood, but that determination alone does not guarantee coverage if the item or service is not included in the member’s benefit plan. In other words, even when Neighborhood’s clinical review concludes that care meets medical necessity criteria, coverage can still be denied or payment not made if the member’s specific benefit documents exclude that service or technology.
Provider Actions & Prior Authorization
Prior Authorization Required
Prior authorization may be required. Providers must consult Neighborhood Health Plan of Rhode Island's PA Search Tool to determine current prior authorization requirements, submission instructions, and any specific documentation needed for the requested service.
Step Therapy Not Specified
Step therapy requirements are not specified in this policy text. Providers should verify if step therapy applies by checking the PA Search Tool and the member's benefit plan prior to initiating therapy.
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