CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Outpatient Surgery Procedure_Auth_Form 2.18.2016 1

A utilization management administrative form for submitting outpatient surgery authorization requests to Neighborhood Health Plan of Rhode Island (NHPRI). It captures member, provider, and clinical information and lists required supporting documentation for medical necessity determinations. It is a submission and processing form rather than a coverage policy.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyOutpatient Surgery Procedure_Auth_Form 2.18.2016 1

Policy CodePolicy N/A

Change TypeAdministrative form (no material change)

Effective Date

Next Review Date

Key ActionReturn completed form to the Utilization Management Department at (401) 459-6023 to request outpatient surgery authorization.

SourceLink

POLICY UPDATE CHANGES

No material clinical/coverage changes — form is an administrative submission template used for outpatient surgery authorization and does not change coverage criteria.

FormDocument Type

4Suggested Supporting Doc Types

NoMaterial Change

Outpatient Surgery Procedure Authorization Form — Overview

This is Neighborhood Health Plan of Rhode Island's (NHPRI) outpatient surgery authorization request form used by the Utilization Management (UM) Department. The form captures member, provider, and procedure details to support the UM review and authorization process. For detailed coverage criteria and specific authorization requirements, please refer to Neighborhood's Clinical Medical Policy available on the NHPRI website.

Required Documentation for Medical Necessity Determination

Documentation of medical necessity for the requested procedure may include one or all of the following:

ANY of the following

Physician Office Notes
Consults and all other evaluations
Results of Diagnostic Testing
Previous Treatment and Outcomes

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Submit the completed form and any supporting clinical documentation to the Utilization Management Department at (401) 459-6023. Include physician office notes, consults/evaluations, diagnostic test results, and prior treatment/outcomes as applicable to support medical necessity determinations during the UM review.

What Providers Must Do

Prior Authorization

Submit completed authorization form

Return completed form to the Utilization Management Department at (401) 459-6023 to request outpatient surgery authorization; form captures member, provider, and procedure details and is required for UM review.

(401) 459-6023
Form captures member, provider, and procedure details and is required for UM review

Documentation Required

Supply supporting clinical documentation

Include physician office notes, consults/evaluations, diagnostic test results, and previous treatment and outcomes as applicable to support medical necessity determinations.

Physician Office Notes
Consults/evaluations
Diagnostic test results
Previous treatment and outcomes

Billing Rule

Authorization is not a guarantee of payment

Authorization decisions are for utilization management and do not guarantee claim payment; retain Authorization # and Dates of Service for billing.

Authorization #: Unique identifier assigned by UM when authorization is approved; used for tracking and billing but does not guarantee payment.
Retain Authorization # and Dates of Service for billing

Form CPT Fields

Request form CPT fieldsCPT

Template contains two generic CPT Code fields and corresponding Units; specific CPT codes to be entered by requester

The form provides generic CPT entry fields (two CPT Code fields with corresponding Units) for requesters to enter procedure codes; it does not list specific covered or excluded CPT codes. For code-level coverage determinations and whether a procedure is covered or excluded, consult NHPRI's Clinical Medical Policy and coverage documents.