CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Out-of-Network / Out-of-Area Services and Continuity of Care

Defines coverage and authorization requirements for services rendered by out-of-network (non-participating) providers or when members are located out-of-area across multiple lines of business, including special rules for Medicare Advantage, transitional continuity of care, foster children, and female members' access to out-of-network women's health specialists.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyOut-of-Network / Out-of-Area Services and Continuity of Care

Policy CodePolicy N/A

Change TypeReviewed / updated (8/20/25)

Effective DateJan 28, 2014

Next Review Date

Key ActionObtain prior authorization for non-emergency care from non-participating providers (except emergent/urgent care and Medicare Advantage dialysis which are authorized without review).

SourceLink

POLICY UPDATE CHANGES

Policy reviewed and updated on 8/20/25 per revision history.

6Key authorization scenarios listed

3-6Transition timeframes (months)

MA dialysisNo auth required

Coverage Summary

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Authorization & Coverage Criteria

General Authorization Determination

Covered emergent/urgent care and certain dialysis are authorized without review; other non-emergent out-of-network/area services require prior authorization except as noted for Medicare Advantage dialysis.

ANY of the following

Emergent and urgent care services rendered in emergency rooms and urgent care centers are authorized without review (no authorization required).
Out-of-Network/Area dialysis is covered with no authorization required for the Medicare Advantage Product population only; all other lines of business require prior authorization.
Requests for non-emergency care including second opinions from non-participating practitioners or providers require prior authorization.
Services requested to preserve continuity of care, namely an on-going clinical relationship (see continuity criteria), require prior authorization.

Criteria for Non-Emergency Out-of-Network Care

Requests for services for non-emergency care from out-of-network practitioners/providers are considered ONLY when ALL of the following are met:

ALL of the following

The service being requested is medically necessary and NOT available within the NHP network.
The member is being 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 services are not available within the current provider network.
ONE of
- Member is temporarily outside the service area and the service cannot be delayed.
- The member is actively undergoing treatment required for an acute medical condition, or is undergoing active treatment for a chronic condition.

Post-Stabilization Care

Neighborhood's financial responsibility for post-stabilization care services that have not been pre-approved ends when ANY of the following occur:

ANY of the following

A plan physician with privileges at the treating hospital assumes responsibility for the enrollee's care.
A plan physician assumes responsibility for the enrollee's care through transfer.
A Neighborhood representative and the treating physician reach an agreement concerning the enrollee's care.
The enrollee is discharged.

Continuity of Care — Ongoing Clinical Relationship

Services requested to preserve continuity of care for an ongoing clinical relationship with a nonparticipating specialty care practitioner are considered when ANY of the following apply:

ANY of the following

Those receiving treatment for an acute medical or behavioral condition or an acute episode of a chronic illness.
Members who are unable to be transitioned to a provider with comparable or greater expertise. If the specialty is available in network, the transition is expected to occur within six (6) months.6 months

Special Transitional Periods and Time Limits

Temporary allowances for transition to in-network providers for specific populations:

ALL of the following

Children in foster care who are RI residents but not living in RI at that time may receive out-of-state care; once living in RI, transfer back to in-network or original provider expected within six (6) months.6 months
Members newly enrolled to CSN, SUB, RHE, MED (Rite Care), RHP, or Medicare Advantage who have an existing relationship with a non-participating provider have six (6) months from enrollment to transition services to a participating provider.6 months
Members newly enrolled to the Health Benefits Exchange (Individual Market) with an existing relationship with a non-participating provider have three (3) months from enrollment to transition to a participating provider under certain circumstances.3 months

Access to Out-of-Network Women's Health Specialists

Female members in specified lines of business are allowed access to out-of-network women's health specialists for routine and preventive services:

Female members enrolled in RIteCare, CSN, SUB, Medicare Advantage Product, RHE, or RHP may access out-of-network women's health care specialists (e.g., obstetricians, gynecologists, certified nurse midwives, nurse practitioners, doulas, or other qualified specialists) for routine and preventive services.

Ancillary Services During Transition

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

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

Provider Actions & Operational Guidance

Prior Authorization

Prior authorization required for non-emergency out-of-network services

Obtain prior authorization for non-emergency care requested from non-participating (out-of-network) practitioners/providers. Emergent and urgent care rendered in emergency rooms and urgent care centers are authorized without review. Out-of-network/out-of-area dialysis is authorized without prior review only for the Medicare Advantage Product; all other lines of business require prior authorization.

Documentation Required

Document medical necessity and network availability

Document that the requested service is medically necessary and not available within the NHP network or that the member meets an allowable continuity/temporary condition. Examples of acceptable documentation include: referral from an in-network provider with the same specialty due to clinical complexity or inability to provide adequate service; member temporarily outside the service area and the service cannot be delayed; or member actively undergoing required treatment for an acute condition or ongoing treatment for a chronic condition.

Referral by an in‑network provider with same specialty citing clinical complexity or inadequate in‑network capacity
Evidence member is temporarily outside the service area and care cannot be delayed
Documentation of ongoing/active treatment for an acute or chronic condition

Billing Rule

Use Authorization Quick Reference Guide for coding

Reference the Authorization Quick Reference Guide for specific covered codes and coding guidance related to out-of-network/out-of-area services. Providers should consult the Neighborhood website for the Authorization Quick Reference Guide and covered codes.

Authorization Quick Reference Guide (see Neighborhood website for covered codes)

Denial Risk

Denial risk when in-network services available

Claims may be denied if the requested service is available within the NHP network and the out-of-network criteria are not met. Verify network availability and that the request meets the listed criteria (medical necessity, in-network referral when required, temporary travel, or ongoing treatment/continuity conditions) before submission to reduce denial risk.

Confirm service is not available in-network
Obtain and include supporting referral or documentation of temporary/continuity reasons before claim submission

Background

This policy defines out-of-network and out-of-area services and sets expectations for continuity of care between clinicians, specifying when Neighborhood will cover services provided by non-participating providers and the conditions under which continuity and transition protections apply. For Medicare Advantage members, Neighborhood follows Centers for Medicare & Medicaid Services (CMS) guidance for coverage and medical necessity determinations (including NCDs, LCDs, LCAs, and other CMS guidance), and when CMS guidance is absent or not met, Neighborhood will apply secondary guidance from Rhode Island Executive Office of Health & Human Services (EOHHS), peer-reviewed evidence such as InterQual®, and internal Clinical Medical Policies. The policy also references operational resources such as the Authorization Quick Reference Guide and prior authorization request forms available on Neighborhood's website as secondary/internal guidance for coding and submission.

Definitions

Out-of-network servicesServices provided to members by practitioners/providers who are not participating in the Neighborhood network.

Out-of-area servicesServices provided by practitioners/providers outside of Rhode Island and its border communities that do not hold a participating provider contract with Neighborhood.

Continuity of CareAn ongoing relationship with a physician or provider familiar with the member's past medical and personal history; clinicians are expected to communicate and coordinate care.

OpenPayer

Out-of-Network / Out-of-Area Services and Continuity of Care

Coverage Summary

Authorization & Coverage Criteria

Provider Actions & Operational Guidance

Coding Reference

Background

Revision History