CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Use of Evidence Based Medicine

Defines when requests that lack specific clinical criteria will be reviewed and covered based on an evidence-based physician review for Neighborhood Health Plan of Rhode Island members across listed product lines.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyUse of Evidence Based Medicine

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJun 15, 2022

Next Review DateApr 8, 2026

Key ActionSubmit prior authorization requests for non-standard services using Neighborhood's provider portal forms so a physician can review evidence for coverage.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

7explicit coverage review criteria items listed

5most recent annual review dates listed

National+LocalMedicare guidance sources

Evidence-Based Coverage Criteria

Evidence-Based Service Coverage Criteria

Covered when ALL of the following are met after physician evidence review

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Primary coverage criteria: The requested service or item is safe and effective; not experimental or investigational; within accepted standards of medical practice; appropriate to the medical needs and condition of the member in the current clinical scenario; available evidence and clinical documentation support that the item/treatment/procedure improves net health outcomes; and the available evidence and clinical documentation support that the item/treatment/procedure is as beneficial as any established alternative or is more beneficial for an identifiable subgroup of individuals.

If the item/treatment/procedure is less safe than existing alternatives but efficacious for patients not adequately treated with existing alternatives, approval may be recommended provided all other criteria are met.

Additional required criteria: The requested service or item is not specifically excluded by another Clinical Medical Policy or treatment guideline.

Provider Requirements and Prior Authorization

Prior Authorization

Prior Authorization Required

Prior authorization is required for requests that lack specific clinical criteria or are non-standard. Requests without clear clinical criteria will undergo physician evidence-based review before coverage determination.

Providers must submit a prior authorization request using Neighborhood's forms available at www.nhpri.org → Providers → Provider Resources → Forms.
Call 1-800-963-1001 for assistance with prior authorization requests or inquiries.
Provide complete clinical documentation to support safety, effectiveness, and accepted practice.

Denial Risk

Reviewer Evaluation Rule

The reviewer will evaluate whether the requested service is safe and effective, not experimental or investigational, within accepted standards of medical practice, appropriate to the member's current clinical needs, and supported by evidence that it improves net health outcomes. The reviewer will also compare the benefit and safety of the request versus established alternatives and may deny the request if it is less safe or not as beneficial as alternatives.

Reviewer will determine if the item/treatment is as beneficial as any established alternative or more beneficial for an identifiable subgroup.
Reviewer will determine if the item/treatment is as safe as existing alternatives; may deny if less safe.
Requests lacking sufficient evidence that the service improves net health outcomes will not meet coverage criteria.

Documentation Required

Provide all relevant clinical documentation and evidence to support the safety, effectiveness, and acceptance of the requested service. Incomplete records may delay review or result in denial.

Include clinical notes, test results, prior treatments, and rationale for use over alternatives.
Reference published evidence or guidelines when available.

Denial Risk

Denial Conditions

Requests will be denied if physician review finds the service is experimental or investigational, or otherwise excluded by Neighborhood clinical policies or plan exclusions.

Services determined to be experimental/investigational will be denied.
Services excluded by other Neighborhood clinical policies or plan contract exclusions will be denied.

Key Definitions

Medically Necessary — Definition

DefinitionMedical, surgical, or other services required for the prevention, diagnosis, cure, or treatment of an injury, health‑related condition, disease, or its symptoms.

EPSDT for Medicaid members <21For Medicaid members under age 21, includes EPSDT services per Section 1905(r) of the Social Security Act, including services necessary to correct or ameliorate a defect or physical or mental illness or condition discovered through EPSDT screenings.

Situational considerationsA service is considered medically necessary when rendered for situations such as (1) response to a life‑threatening condition or pain, or (2) to treat an injury, illness, or infection.

Experimental or Investigational — Definition

DefinitionServices for which reliable evidence shows further studies are necessary to determine safety or efficacy, or that do not improve net health outcomes or are not as beneficial as established alternatives.

Implication for coverageSuch services are considered investigational/experimental and are generally not covered unless there is sufficient high‑quality evidence establishing safety and efficacy.

Evaluation requirementRequests suspected to be experimental or investigational will be reviewed by a physician using available evidence to determine whether further study is needed or whether the service meets standards of care.

OpenPayer

Use of Evidence Based Medicine

Evidence-Based Coverage Criteria

Coding and Billing

Provider Requirements and Prior Authorization

Policy Background

Key Definitions