CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

prior_authorization_request_form

A form and instructions for providers to request prior authorization from Neighborhood Health Plan of Rhode Island's Utilization Management Department, including member, provider, clinical information, checklist of supporting documentation, and UM decision fields. It references the payer's Clinical Medical Policy for coverage criteria.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

Policyprior_authorization_request_form

Policy CodePolicy N/A

Change TypeInformational

Effective Date

Next Review Date

Key ActionReturn completed form to the Utilization Management Department by fax to (401) 459-6023 or telephone as provided; include member, provider, procedure (CPT and units), scheduled date, and supporting clinical documentation to allow a medical necessity determination.

POLICY UPDATE CHANGES

No material clinical/coverage changes

1Form Pages

4Required Supporting Document Types Listed

Prior Authorization Request Form — Purpose & Scope

This form facilitates submission of prior authorization requests to Neighborhood Health Plan of Rhode Island's Utilization Management (UM) Department. Providers should return the completed form to the Utilization Management Department by fax or telephone as provided and include member, provider, procedure (CPT and units), scheduled date, and supporting clinical documentation to allow a medical necessity determination.

Key Metadata

payerNeighborhood Health Plan of Rhode Island

policyPrior Authorization Request Form

policy_number

effective_date

next_review_date

statusCURRENT

scope_summaryA form and instructions for providers to request prior authorization from Neighborhood Health Plan of Rhode Island's Utilization Management Department, including member, provider, clinical information, checklist of supporting documentation, and UM decision fields. It references the payer's Clinical Medical Policy for coverage criteria.

What Providers Must Do

Prior Authorization

Submit completed prior authorization form

Return completed form to the Utilization Management Department by fax to (401) 459-6023 or telephone as provided; include member, provider, procedure (CPT and units), scheduled date, and supporting clinical documentation to allow a medical necessity determination.

Documentation Required

Include supporting clinical information

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

Documentation Required

Provide prior authorization identifiers

Include Previous Auth # (if any) and requested Dates of Service; UM will return an Authorization #, Dates of Service approved, Services Approved, UM initials, and Notification Date.

Billing Rule

Authorization not a guarantee of payment

Authorization decision field indicates that authorization is not a guarantee of payment; providers should verify payment eligibility per payer rules.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

Policyprior_authorization_request_form

Policy CodePolicy N/A

Change TypeInformational

Effective Date

Next Review Date

On This Page

OpenPayer

prior_authorization_request_form

Prior Authorization Request Form — Purpose & Scope

Procedure Codes

What Providers Must Do

Terms

Document Revision Timeline