Request to Review/Create a Clinical Medical Policy/Request for Coverage
A submission form for requesting creation or modification of Neighborhood Health Plan of Rhode Island clinical medical policies and coverage decisions; used by internal or external requestors to propose new policies or changes and supply supporting information.
No material clinical or coverage changes in this revision.
Coverage Criteria
This form is a mechanism to request the creation or modification of Neighborhood Health Plan of Rhode Island clinical medical policies or coverage decisions. It does not itself establish coverage criteria, exclusions, or medical necessity rules, nor does it authorize clinical services or substitute for any prior authorization process. Requestors should provide a description of the new policy or proposed modifications and attach supporting literature or standards of practice to inform policy development.
Provider Actions & Submission Instructions
Policy/coverage request (no direct PA effect)
This form is to request creation of a new clinical medical policy, to request modification of an existing clinical medical policy, or to request addition of coverage for a service or product. Completing and submitting this form does not itself authorize services and does not substitute for any existing prior authorization or coverage determinations.
- Type of Action Requested: New clinical medical policy; Request to modify existing clinical medical policy; Add coverage for service or product.
- CMP Name and description: Provide name and describe the clinical policy requirement or recommended modification; include references or documented standards of practice and attach supporting literature if available.
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