Prior authorization/medical necessity request form (template)
This document is a provider-facing authorization request form and checklist used to submit clinical information to Neighborhood Health Plan of Rhode Island for utilization management review. It outlines required member, provider, and clinical information to support a medical necessity determination; it does not itself define coverage criteria.
No material clinical or coverage changes in this revision.
Form purpose and scope
This document is a standard cover form and checklist used by the payer's Utilization Management (UM) department to collect necessary member, provider, and clinical information for a medical necessity review; it functions as an intake form rather than a policy that defines coverage criteria. The form outlines required fields for member and provider identification, requested CPT code(s) and units, diagnosis and procedure description, and a checklist of supporting documentation (including physician office notes, consults and other evaluations, results of diagnostic testing, and previous treatment and outcomes) to support a medical necessity determination. Providers are instructed to return the completed form to the Utilization Management Department at (401) 459-6023, and to refer to Neighborhood's Clinical Medical Policy on the Neighborhood website for detailed benefit, authorization requirements, and coverage criteria.
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