CurrentNeighborhood Health Plan of Rhode IslandPolicy # 075

Evidence Based Services Coverage Policy

Defines criteria under which requests for services/items not addressed by established medical criteria will be reviewed and covered by Neighborhood Health Plan of Rhode Island across all lines of business; specifies the physician evidence-based review process and documentation/authorization pathways.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyEvidence Based Services Coverage Policy

Policy CodePolicy # 075

Change TypeClarified (no substantive change)

Effective DateApr 9, 2025

Next Review Date

Key ActionProviders should submit a prior authorization request; requests not addressed by established criteria will be forwarded to a physician reviewer who will evaluate evidence and determine coverage based on the six coverage criteria.

SourceLink

POLICY UPDATE CHANGES

Policy last reviewed and revision date listed as 04/09/25 with annual review month April; no substantive change noted in document.

AllLines of Business Covered

NoneExcluded from Coverage

AnnualReview Frequency

Coverage Summary

When a prior authorization request cannot be evaluated using existing medical criteria (for example, NCDs, LCDs, InterQual®, or Clinical Medical Policies), the request is forwarded to a medical doctor reviewer who evaluates the request using current evidence-based medicine resources to determine coverage.

This physician evidence-based review process is used across all lines of business and, for Medicare Advantage members, Neighborhood follows CMS guidance (including applicable payment policies, NCDs, LCDs, and other CMS published guidance). In the absence of applicable or complete CMS guidance, Neighborhood will apply state EOHHS guidance or peer-reviewed scientific evidence as secondary coverage guidance. Subject: Evidence Based Services Coverage Policy; Scope: defines the physician evidence-based review process and applies to requests for services/items not addressed by established medical criteria.

Policy Metadata

Policy Number# 075

Effective Date2025-04-09

Last Review2025-04-09

StatusCURRENT

Scope SummaryDefines criteria under which requests for services/items not addressed by established medical criteria will be reviewed and covered by Neighborhood Health Plan of Rhode Island across all lines of business; specifies the physician evidence-based review process and documentation/authorization pathways.

Lines of Business CoveredAll

Medical Necessity / Coverage Criteria

Coverage Determination for Evidence Based Services

Requests for Evidence Based Services are covered ONLY when physician review shows that ALL of the following criteria are met:

ALL of the following

The requested service or item is safe and effective
The requested service or item is not experimental or investigational
The requested service or item is within accepted standards of medical practice
The requested service or item is appropriate to the medical needs and condition of the member in the current clinical scenario
The requested service or item is not specifically excluded by another Clinical Medical Policy or treatment guideline
The requested service or item is ordered and furnished by qualified personnel

Coverage Determination for Evidence Based Services

Provider Actions & Submission Requirements

Prior Authorization

Physician evidence-based review required

When a requested service or item is not addressed by existing medical criteria, the request will be forwarded to a physician reviewer who will evaluate current evidence and determine coverage based on the policy's six coverage criteria. Providers should submit a prior authorization request so the physician reviewer can evaluate the request.

Documentation Required

Sources available to physician reviewer

The physician reviewer may use resources such as Cochrane Reviews, PubMed, current society guidelines, ICER, Hayes, UpToDate, other payer policies, or external expert specialty opinion when formulating a decision. Providers are advised to supply relevant clinical evidence to support their requests.

Billing Rule

Authorization form access and assistance

Prior authorization request forms are available on Neighborhood's website (www.nhpri.org) under Providers -> Provider Resources -> Forms -> 'Click here for a list of prior authorization request forms'. For assistance, providers may call 1-800-963-1001 (phone messaging system available during and outside business hours).

Background

Neighborhood Health Plan of Rhode Island generally utilizes existing coverage guidelines for most review scenarios, but when a request cannot be adequately evaluated using established medical criteria (for example, CMS National Coverage Determinations, Local Coverage Determinations, InterQual®, or existing Clinical Medical Policies), the request is forwarded to a physician reviewer who will review the request using current evidence-based medicine. The physician reviewer may use resources such as Cochrane Reviews, PubMed, current society guidelines, ICER, Hayes, UpToDate, other applicable third‑party payer policies, or external expert specialty opinion when formulating a decision.

For Medicare Advantage members, Neighborhood uses guidance from the Centers for Medicare & Medicaid Services (CMS) for coverage determinations, including medical necessity, based on applicable payment policies, NCDs, LCDs, LCAs, and other CMS published guidance. If an applicable NCD, LCD, or other CMS guidance is absent or incomplete, or available Medicare coverage guidance is not met, Neighborhood will apply coverage guidance from the Rhode Island Executive Office of Health & Human Services (EOHHS) or other peer‑reviewed scientific evidence (such as InterQual® or internal Clinical Medical Policies) as a means of secondary coverage through the member's Medicaid benefit.

Coverage determinations for requests reviewed under this policy are covered ONLY when the physician review shows that ALL required criteria are met: the service/item is safe and effective; not experimental or investigational; within accepted standards of medical practice; appropriate to the member's medical needs in the current clinical scenario; not specifically excluded by another Clinical Medical Policy or treatment guideline; and ordered and furnished by qualified personnel.

Providers should submit prior authorization requests and may be asked to provide relevant clinical evidence to support requests. Prior authorization forms and assistance are available on Neighborhood's website and by phone. Neighborhood reviews Clinical Medical Policies annually; review and approval dates are listed (for example: 6/15/22, 6/7/23, 4/10/24, 4/9/25).

Revision History

2022-06policy_creation

Clinical Medical Policy (CMP) created June 2022.

2022-06-15review_approval_effective

Review date, Medical Director approval, and effective date recorded as 6/15/22.

2023-06-07review_approval_effective

Review date, Medical Director approval, and effective date recorded as 6/7/23.

2024-04-10review_approval_effective

Review date, Medical Director approval, and effective date recorded as 4/10/24.

2025-04-09last_review_revision_effectiveLatest

Policy last reviewed and revised on 04/09/25; review date, Medical Director approval, revision date, and effective date recorded as 4/9/25. Annual review month: April.

2025-04-09policy_effective_dateLatest

Policy effective date listed as 04/09/25.

2025-04-09last_review_dateLatest

Policy last reviewed on 04/09/25.