CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Out-of-Network / Continuity of Care Coverage

Defines when Neighborhood Health Plan of Rhode Island will cover services from out-of-network providers and rules for preserving continuity of care across its lines of business; affects plan members and their treating providers.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyOut-of-Network / Continuity of Care Coverage

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization for non-emergent out-of-network services; emergent and urgent care are authorized without review.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

6 monthsstandard transition (most LOB)

3 monthsExchange transition (some)

No authemergent/urgent care

CMS guidanceMedicare Advantage

Allowedwomen's health access

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Covered when criteria met

Services from out-of-network practitioners are considered covered when ALL/OR of the specified conditions below are met.

When out-of-network non-emergency care may be considered: Any of the following: (1) the service requested is medically necessary and not available within the NHP network; (2) the member is referred by an in‑network provider with the same specialty as the out‑of‑network provider due to clinical complexity or inability to provide adequate service AND the services are not available within the current provider network; (3) the member is temporarily outside the service area and the service cannot be delayed; (4) the member is actively undergoing treatment required for an acute medical condition or is undergoing active treatment for a chronic condition.

Based on chunk 5.

Post-stabilization care termination conditions: Neighborhood's financial responsibility for post‑stabilization care that was not pre‑approved ends when one of the following occurs: (a) a plan physician assumes responsibility for the enrollee's care through transfer; (b) a plan physician with privileges at the treating hospital assumes responsibility for the enrollee's care; (c) a Neighborhood representative and the treating physician reach an agreement concerning the enrollee's care; (d) the enrollee is discharged.

Based on chunk 5.

Continuity of care / transition timelines: Services to preserve continuity of care for ongoing clinical relationships with nonparticipating specialty practitioners are allowed. If the specialty is available in‑network, transition is expected within six (6) months. Children in foster care returning to Rhode Island are expected to transition within six (6) months. Members newly enrolled who have an existing relationship with a non‑participating practitioner/provider have six (6) months from the date of enrollment to transition for most specified product lines; for the Health Benefits Exchange (individual market) certain circumstances allow a three (3) month transition period.6 months / 3 months

Based on chunk 6.

Women’s health access: Female members enrolled in specified lines of business (RiteCare, Children with Special Health Care Needs, Substitute Care, Medicare Advantage, Rhody Health Expansion, Rhody Health Partners) are allowed access to an out‑of‑network women's health care specialist for routine and preventive services. A women's health care specialist may include obstetricians, gynecologists, certified nurse midwives, nurse practitioners, doulas, or another qualified health care professional specializing in women's health.

Based on chunk 7.

Ancillary services during transition: Ancillary services required during the transition period for new members are covered until the practitioner/provider becomes contracted or the member can safely be redirected to an in‑network practitioner/provider with comparable or greater expertise.

Based on chunk 7.

Extended Family Planning (EFP) is excluded from coverage and is not payable under this policy.

Coding and Transition Periods

Covered Codes referencemixed

No codes listed

Transition period

Standard transition period6 months for most lines of business for members with an existing relationship to a non‑participating provider.

Exchange (individual) transition period3 months for Health Benefits Exchange (individual market) members in certain circumstances.

Newly enrolled members covered linesSix months applies to members newly enrolled to CSN, SUB, RHE, Rite Care (MED), RHP, or Medicare Advantage to transition to participating providers.

Foster care childrenChildren in foster care returning to Rhode Island are expected to transition back to an in‑network or original provider within six months.

Expectation when specialty available in‑networkIf the specialty is available in‑network, transition to an in‑network provider is expected within six months.

Provider Requirements and Authorization

Prior Authorization

Prior Authorization Required

Prior authorization is required for non-emergent out-of-network services except for authorized emergent/urgent care and certain dialysis for Medicare Advantage members. Requests for non-emergency care from out-of-network providers are considered only when criteria are met (see Criteria section). If criteria are not met, the request may be denied.

Covered emergent and urgent care services are authorized without review.
Out-of-network/area dialysis is covered with no authorization required for the Medicare Advantage product only; other lines of business require prior authorization.

Step Therapy

Transition / Step Expectations

Members must be transitioned to in-network providers when an in-network specialty is available. If the specialty is available in-network, transition to an in-network provider is expected within six months. Specific enrollment groups (e.g., Children with Special Health Care Needs, Medicare Advantage) have defined transition timeframes: generally six months from date of enrollment; Health Benefits Exchange (Individual Market) may have a three-month transition under certain circumstances.

If specialty is available in-network, transition expected within six months.
Newly enrolled members with existing relationships in specified lines of business have six months to transition.
Health Benefits Exchange (Individual Market) members may have a 3-month transition under certain circumstances.

Note

How to Submit Authorization

Authorization request forms are available on Neighborhood's website: Providers > Provider Resources > Forms. Providers may contact Neighborhood for assistance via the provider phone line at 1-800-963-1001. For coding information, reference the Authorization Quick Reference Guide.

Website path: Providers → Provider Resources → Forms (forms listed alphabetically).
Provider assistance: call 1-800-963-1001.
See Authorization Quick Reference Guide for covered codes and coding guidance.

Denial Risk

PROVIDER ACTIONS

Requests for non-emergency care from out-of-network providers are considered only when criteria are met (medical necessity and not available in-network, referral by an in-network provider of same specialty when due to clinical complexity or inability to provide adequate service, member temporarily outside service area, active ongoing treatment, or to preserve continuity of care). If criteria are not met, the request may be denied; post-stabilization care financial responsibility ends according to transfer/discharge provisions.

Services must be medically necessary and not available within the NHP network.
Referral by an in-network provider of same specialty required when referral is due to clinical complexity or inability to provide adequate service.
Temporary absence from service area or active ongoing treatment are acceptable reasons.
Requests to preserve continuity of care (ongoing clinical relationship) are considered; specific groups and situations have time-limited transition expectations.
Post-stabilization care: Neighborhood's financial responsibility ends when a plan physician assumes care, a plan physician with hospital privileges assumes care, agreement reached between Neighborhood and treating physician, or the enrollee is discharged.

Background and Purpose

Continuity of care refers to an ongoing clinical relationship with a clinician who is familiar with the member's medical and personal history and is intended to preserve treatment during acute or chronic episodes when continuity is clinically important. Neighborhood evaluates medical necessity and local availability when considering requests to preserve continuity of care with an out-of-network provider.

When continuity of care is being preserved for members with an existing relationship to a nonparticipating specialty practitioner, services may be allowed for a defined transition period. If the specialty is available in-network, the expectation is that the member will transition to an in-network provider within 6 months for most lines of business and within 3 months for certain Health Benefits Exchange (individual market) members in applicable circumstances.

Definitions

Out-of-network services

DefinitionServices, treatments, and/or procedures provided to members by practitioners or providers who are not participating in the Neighborhood Health Plan of Rhode Island network.

ScopeIncludes services rendered when the member is located out‑of‑area or when the treating provider does not hold a participating contract with Neighborhood.

Relation to coverageSuch out‑of‑network services are considered covered benefits only when conditional criteria (see Coverage Criteria) are met.

Continuity of Care

DefinitionAn ongoing clinical relationship with a physician or other health care provider that endures over time; the provider is expected to be familiar with the member's medical and personal history.

PurposeContinuity of care preserves treatment during acute or chronic episodes when ongoing provider familiarity is clinically important.

Transition expectationWhen continuity is being preserved with a nonparticipating specialist and an in‑network specialty exists, the member is expected to transition to an in‑network provider (typically within six months; three months for certain Exchange members).

Application to foster care and new membersApplies to children in foster care and newly enrolled members who have existing relationships with nonparticipating providers; transition timelines described in policy.

OpenPayer

Out-of-Network / Continuity of Care Coverage

Coverage Criteria for Out-of-Network and Continuity of Care

Coding and Transition Periods

Provider Requirements and Authorization

Background and Purpose

Definitions