CurrentNeighborhood Health Plan of Rhode IslandPolicy Non-Standard Requests- #046

Non-Standard Requests (Clinical Medical Policy #046)

Defines the framework and general coverage criteria Neighborhood Health Plan of Rhode Island uses to evaluate conditional or non-standard medical services that lack a specific clinical medical policy, including sources of evidence, required criteria for medical necessity, exclusions for experimental/investigational care, and administrative processes for authorization.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyNon-Standard Requests (Clinical Medical Policy #046)

Policy CodePolicy Non-Standard Requests- #046

Change TypeRevision (04/09/25)

Effective DateJun 20, 2014

Next Review Date

Key ActionSubmit authorization requests via Neighborhood's Authorization Request Forms on the provider portal and include supporting scientific evidence and clinical documentation to demonstrate improved net health outcomes and safety compared to alternatives.

POLICY UPDATE CHANGES

Revision dates listed include 04/09/25 indicating the policy was revised on that date.

AnnualReview cadence

AllLines of Business covered

NoneExplicit exclusions (none listed)

Coverage Summary — Non-Standard Requests (Policy #046)

Scope: Defines the framework and general coverage criteria Neighborhood Health Plan of Rhode Island uses to evaluate conditional or non-standard medical services that lack a specific clinical medical policy, including sources of evidence, required criteria for medical necessity, exclusions for experimental/investigational care, and administrative processes for authorization.

Definitions & Background

This policy provides the framework for evaluating conditional or non-standard treatments and procedures when no specific clinical medical policy exists. Neighborhood uses guidance from governmental and scientific sources including Centers for Medicare & Medicaid Services (CMS), Food and Drug Administration (FDA), Centers for Disease Control (CDC), peer-reviewed literature, and state Executive Office of Health & Human Services (EOHHS) guidance to inform Medicare/Medicaid distinctions and coverage determinations.

The policy specifies that services are assessed through utilization review (prospective, concurrent, or retrospective) and that Neighborhood will follow limitations indicated by scientific evidence and standards of practice.

Experimental or investigational services are excluded from coverage unless coverage is required by law.

Term	Definition
Medically necessary services	Services necessary to treat health-related conditions, including those necessary to prevent a detrimental change in a member's medical or mental health status, provided in the most cost-effective and appropriate setting.
Experimental/Investigational services	Services not recognized as proven effective in clinical medicine; Neighborhood evaluates published scientific evidence to determine inclusion in the benefit package.

Provider Requirements & Authorization

Prior Authorization

Authorization required for non-standard requests

Prospective, concurrent, or retrospective assessment via utilization review will determine medical necessity; providers must submit authorization requests using Neighborhood's Authorization Request Forms available on the provider portal.

Documentation Required

Clinical evidence and documentation requirement

Providers must supply scientific evidence and clinical documentation supporting improved net health outcomes and safety compared to alternatives to justify approval.

Billing Rule

Reference to Authorization Quick Reference Guide for coding

For coding information related to covered services, providers should reference the Authorization Quick Reference Guide.

Coding Reference

Covered Codes (general reference)mixed

No codes listed

For specific coding related to covered services, providers should consult the Authorization Quick Reference Guide.

Providers must submit authorization requests and supporting documentation via Neighborhood's provider portal and Authorization Request Forms as part of the prospective, concurrent, or retrospective utilization review process; check the provider portal for the most up-to-date coding and form information.

Revision History

2025-04-09revisionLatest

Policy revised on 04/09/25; listed in revision history and reflected as last reviewed date.

2017-05-17revision

Revision listed in policy revision history (05/17/17).

2014-06-20effective

Policy effective date listed as 06/20/14.

annualreview_cadence

Neighborhood reviews clinical medical policies on an annual basis.