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

Non-Standard Requests / Conditional Benefits (Medical Necessity Framework)

Defines the general medical necessity criteria Neighborhood Health Plan of Rhode Island uses to evaluate conditional or non-standard benefits that do not have a specific clinical medical policy; applies to all lines of business and to utilization review processes (prospective, concurrent, retrospective).

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyNon-Standard Requests / Conditional Benefits (Medical Necessity Framework)

Policy CodePolicy Non-Standard Requests- # 046

Change TypeNo material changes

Effective Date6/20/14 (multiple updates through 4/10/24)

Next Review Date

Key ActionProviders must submit authorization requests using Neighborhood's prior authorization request forms on the payer website and include clinical documentation demonstrating safety, efficacy, and improved net health outcomes.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

All Lines of Businessapplies to

Noneexplicitly excluded from coverage

Annualpolicy review frequency

CMP-046policy internal identifier

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This policy establishes a general framework for evaluating conditional benefits and non-standard requests that do not have a dedicated clinical medical policy. Decisions are made through utilization review (prospective, concurrent, and retrospective) and rely on governmental guidance (CMS, FDA, CDC), peer-reviewed evidence, and internal clinical policies to determine medical necessity and appropriate allocation of services. The framework applies across all lines of business and supports consistent, evidence-based determinations when a specific clinical policy is not available.

At-a-Glance

applies toAll Lines of Business

explicitly excluded from coverageNone

policy review frequencyAnnual

policy internal identifierCMP-046

General Medical Necessity Criteria

ALL of the following criteria must be met in order for a recommended service to be approved:

ALL of the following

Where applicable, the treatment/procedure must have final approval from the appropriate governmental bodies.
Scientific evidence must permit reliable conclusions to be drawn about the effect of the treatment/procedure on health outcomes.
The available evidence and clinical documentation must support the conclusion that the treatment/procedure improves net health outcomes.
Evidence vs alternatives
- The available evidence and clinical documentation must support the conclusion that the treatment/procedure is as beneficial as any established alternative.
- OR the treatment/procedure is more beneficial than existing alternatives for an identifiable subgroup of individuals.
Safety standard
- The available evidence and clinical documentation must support the conclusion that the treatment/procedure is as safe as existing alternatives.
- ALL of the following
  - If the treatment/procedure is less safe than existing alternatives, it may still be recommended provided it is efficacious for patients not adequately treated with existing alternatives.
  - All other criteria (including the evidence and benefit criteria above) must be met.

Provider Requirements & Risks

Prior Authorization

Prior Authorization Required via Forms

Providers must submit prior authorization requests using Neighborhood's prior authorization request forms available on the payer website; telephone assistance is available at 1-800-963-1001.

Website: www.nhpri.org → Providers → Provider Resources → Forms → 'Click here for a list of prior authorization request forms'
Phone: 1-800-963-1001 for prior authorization assistance

Documentation Required

Clinical Documentation to Support Medical Necessity

Requests must include clinical documentation and evidence that address safety, efficacy, and demonstrate improved net health outcomes; documentation should also compare the treatment/procedure to established alternatives and provide the scientific evidence used in determinations.

Denial Risk

Experimental/Investigational Exclusion

Services designated as experimental or investigational are not covered and such designation is a basis for denial, except where coverage is required by law.

Key Definitions

Medically NecessaryServices required for prevention, diagnosis, cure, or treatment of health-related conditions including prevention of detrimental change in medical or mental health status; provided in the most cost-effective and appropriate setting and not solely for convenience.

Experimental and/or InvestigationalServices not recognized as proven effective in clinical medicine; Neighborhood evaluates such technologies through a formal mechanism and generally excludes them unless required by law or included after review.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyNon-Standard Requests / Conditional Benefits (Medical Necessity Framework)

Policy CodePolicy Non-Standard Requests- # 046

Change TypeNo material changes

Effective Date6/20/14 (multiple updates through 4/10/24)

Next Review Date

SourceLink

On This Page

OpenPayer

Non-Standard Requests / Conditional Benefits (Medical Necessity Framework)

Policy Snapshot

General Medical Necessity Criteria

Codes & Coding Reference

Provider Requirements & Risks

Key Definitions

Policy Dates & Reviews

Non-Standard Requests / Conditional Benefits (Medical Necessity Framework)

Policy Snapshot

General Medical Necessity Criteria

Codes & Coding Reference

Provider Requirements & Risks

Key Definitions

Cross‑References

Policy Dates & Reviews