CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Levels of Care Authorization — Medical Necessity and Authorization Criteria

Defines medical necessity and authorization processes Neighborhood Health Plan of Rhode Island uses to determine appropriate levels of care (acute, LTAC, inpatient rehab, SNF/subacute, outpatient) and who it affects (providers and covered members, excluding certain product lines).

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyLevels of Care Authorization — Medical Necessity and Authorization Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateFeb 12, 2025

Next Review DateFeb 12, 2025

Key ActionSubmit authorization requests using Neighborhood's prior authorization process; requests will be reviewed against InterQual and CMP criteria.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

InterQual-basedprimary clinical criteria source

MultipleApplies to LOC

ListedExcluded products

02/12/25effective

Coverage and Medical Necessity Criteria

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General medical necessity and LOC criteria

Covered when medical necessity is demonstrated and InterQual or applicable CMS criteria are met for the requested level of care.

Primary criteria: Request meets InterQual criteria for the specific level of care (Acute Adult/Pediatric, Long Term Acute Care, Inpatient Rehabilitation, Subacute/SNF, Outpatient) or applicable CMS NCD/LCD guidance.InterQual or CMS criteria met

When InterQual criteria are not met the case (with collected information) is presented to the Associate Medical Director (AMD) or Physician Reviewer for a final determination.

Documentation: Required clinical documentation is provided, including progress notes, diagnostic results, consultant summaries, operative/pathology reports, and rehabilitation evaluations/progress/attendance as appropriate for the requested level of care.sufficient documentation

Insufficient documentation may lead to denial and cases may be referred to the AMD/Physician Reviewer.

Hierarchy of evidence: When CMS National Coverage Determinations (NCDs) or Local Coverage Determinations (LCDs) apply, those take precedence over other criteria.use CMS guidance when available

In the absence of applicable CMS guidance, Neighborhood will apply peer-reviewed evidence, internal Clinical Medical Policies (CMPs), and InterQual criteria.

LOC specifics: InterQual subsets are used for level-of-care determinations (examples: Acute Adult condition lists, LTAC categories, Inpatient Rehabilitation, Subacute/SNF). Discharge planning should begin at onset of each level of care and extended services for discharge planning will be evaluated by the AMD/Physician Reviewer.InterQual LOC applied

Neighborhood will provide a copy of the InterQual criteria used to render a decision.

This policy applies to determinations of medical necessity and level-of-care (LOC) using InterQual and applicable CMS guidance for Neighborhood Health Plan of Rhode Island members. It does not apply to the following product lines: RiteCare (MED), Substitute Care (SUB), Children with Special Needs (CSN), Rhody HealthPartners (RHP), Medicare‑Medicaid Plan (MMP) Integrity, Rhody Health Expansion (RHE), Health Benefit Exchange (HBE), and Extended Family Planning. Providers should use the appropriate authorization and review processes for members covered under other product lines not listed here.

Services that do not meet the applicable InterQual criteria for the requested level of care or do not meet applicable CMS NCD/LCD guidance are considered not medically necessary and are not covered. In addition, procedures or treatments identified as experimental or investigational (see CMP #026) are not covered except as required by law.

Provider Requirements and Authorization Processes

Prior Authorization

Prior Authorization Required

Prior authorization is required for services when specified by Neighborhood and requests are reviewed against InterQual (and CMS criteria when applicable). Authorization requests must follow Neighborhood's prior authorization process; forms and the Authorization Quick Reference Guide are available on the provider portal (Providers > Provider Resources > Forms). Providers may call 1-800-963-1001 for assistance and there is a phone messaging system for inquiries both during and outside business hours.

Refer to InterQual/CMS criteria during review
Authorization forms and quick reference available on provider portal
Provider help line: 1-800-963-1001

Step Therapy

Step Therapy Not Applicable

This policy does not impose step therapy requirements.

Documentation Required

Required Documentation for Medical Necessity Review

When a medical necessity review is required, providers must supply all applicable medical record elements to support the request. The Utilization Management Nurse (UMN) and/or Associate Medical Director (AMD) or Neighborhood physician reviewer will request and consider these documents during review.

Progress notes describing history of the current problem, status, and current treatment plan
Patient psychosocial history as appropriate and related to the current problem
Diagnostic test results pertinent to the requested service
Consultant summaries and notes
Operative and pathology reports, when applicable
Rehabilitation evaluations, progress notes, attendance, and adherence

Denial Risk

Denial Risk When InterQual Not Met

Requests that do not meet InterQual criteria or that lack sufficient documentation will be escalated to the Associate Medical Director or Physician Reviewer for determination and may be denied if medical necessity is not supported.

Cases not meeting InterQual are presented to AMD/Physician Reviewer
Insufficient documentation may result in denial

Background and Guiding Sources

Neighborhood uses InterQual criteria as the primary clinical reference for determining medical necessity and appropriate level of care (including Acute Adult/Pediatric, Long‑Term Acute Care, Inpatient Rehabilitation, and Subacute/SNF). When applicable, CMS National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs) and Medicare manuals take precedence. Utilization review (prospective, concurrent, and retrospective) is performed by clinical reviewers, and cases that do not meet InterQual criteria are presented to the Associate Medical Director or Physician Reviewer for final determination.

Key Definitions

Medical necessity — definition for services needed for prevention, diagnosis, cure, or treatment

DefinitionServices needed for the prevention, diagnosis, cure, or treatment of a health-related condition, including those necessary to prevent a detrimental change in the member's medical or mental health status; must be provided in the most cost‑effective and appropriate setting and not solely for the convenience of the member or provider.

Evidence baseMedical necessity determinations use InterQual® evidence‑based clinical criteria and Neighborhood’s Clinical Medical Policies (CMPs); when CMS NCDs/LCDs apply, those take precedence.

Setting requirementServices must be provided in the most cost‑effective appropriate setting consistent with the member’s clinical needs.

Documentation roleMedical necessity review compares submitted clinical documentation to InterQual® (or applicable CMS) criteria; insufficient documentation may lead to denial or escalation to the Associate Medical Director/Physician Reviewer.

Review processUtilization review (prospective, concurrent, retrospective) is performed using InterQual®; cases not meeting criteria are presented to the AMD/Physician Reviewer for final determination.

Levels of Care (LOC) — care settings evaluated with InterQual

Acute Adult & PediatricAcute Adult and Acute Pediatric inpatient levels of care are evaluated using InterQual® criteria.

Long Term Acute Care (LTAC)Long Term Acute Care is evaluated using InterQual® criteria (including medically complex, respiratory complex, wound/skin, ventilator weaning subsets as applicable).

Inpatient RehabilitationInpatient rehabilitation admissions are evaluated against InterQual® inpatient rehabilitation criteria to determine appropriateness and intensity of services.

Subacute / SNF (Skilled Nursing Facility)Subacute/SNF level of care determinations use InterQual® criteria; level/intensity for SNF authorizations also considers ordered skilled services and clinical condition.

Outpatient servicesOutpatient services are reviewed using InterQual® and relevant CMP guidance to determine appropriateness of the requested services and level of care.

OpenPayer

Levels of Care Authorization — Medical Necessity and Authorization Criteria

Coverage and Medical Necessity Criteria

Coding and Billing References

Provider Requirements and Authorization Processes

Background and Guiding Sources

Key Definitions