CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Termination of pregnancy (abortion) coverage — Coverage and authorization criteria

Policy governing coverage and authorization requirements for termination of pregnancy for Neighborhood Health Plan of Rhode Island members across specified lines of business; specifies when authorization is required and criteria for Medicaid-funded terminations.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyTermination of pregnancy (abortion) coverage — Coverage and authorization criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionFor Medicaid-funded terminations, submit the Physician Certification Form certifying rape or incest or provide written documentation when pregnancy threatens the mother's life.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

22wgestational age limit for option

8 lineslines of business listed

EFPexplicit exclusion

No authauth not required (most plans)

Coverage Criteria for Termination of Pregnancy

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Approval criteria (<=22 weeks)

Covered when ONE of the following is met for patients less than 22 weeks gestation:

ONE of the following: Pregnancy as a result of rape or incest.gestation <22 weeks

For Medicaid-funded terminations, the treating practitioner must submit a signed statement certifying the pregnancy resulted from rape or incest using Neighborhood's Physician Certification Form for Termination of Pregnancy.

ONE of the following: Termination to preserve the life of the mother when the pregnancy threatens her with mortality risks.gestation <22 weeks

When termination is performed due to a life‑threatening maternal condition, the treating practitioner must submit written documentation describing the impact of the pregnancy on the mother's condition.

This policy does not apply to members enrolled under the Extended Family Planning (EFP) line of business. Providers should not use this policy to determine coverage or authorization for services rendered to EFP members.

Provider Actions, Authorization, and Documentation

Prior Authorization

Prior authorization — when not required

No prior authorization is required for MEDICAID, most COMMERCIAL plans (Innovation, Community, Plus, Edge, Premier, Premier Elite, Prime, Prime Elite, Standard, and Choice), INTEGRITY for Duals, and Duals CONNECT lines of business.

MEDICAID and listed COMMERCIAL plans: no authorization required

Prior Authorization

Prior authorization — when required

For COMMERCIAL plans Value, Essential, and Economy, providers must submit a request for medical necessity review to Neighborhood. The treating practitioner (PCP, Gynecologist, or Obstetrician/Gynecologist) must complete Neighborhood's Physician Certification Form for Termination of Pregnancy available on the website to request authorization.

COMMERCIAL (Value, Essential, Economy): medical necessity review required
Use Neighborhood's Physician Certification Form for Termination of Pregnancy (available on www.nhpri.org)

Note

How to request authorization

Providers should access and submit Neighborhood's prior authorization request forms via the website: go to Providers → Provider Resources → Forms → 'Click here for a list of prior authorization request forms'. For assistance or to inquire about requests, call Provider Services at 1-800-963-1001. For coding guidance, reference the Authorization Quick Reference Guide on the website.

Website: www.nhpri.org → Providers → Provider Resources → Forms → prior authorization request forms
Phone: 1-800-963-1001 for assistance
See Authorization Quick Reference Guide for covered codes

Documentation Required

Required documentation for Medicaid-funded terminations

When requesting Medicaid-funded terminations due to rape or incest, the treating practitioner must submit a signed statement certifying the pregnancy resulted from rape or incest and must complete Neighborhood's Physician Certification Form for Termination of Pregnancy. When the termination is due to a life‑threatening condition of the mother, the treating practitioner must submit written documentation describing the impact of the pregnancy on the mother's condition.

Rape or incest: signed practitioner statement certifying pregnancy resulted from rape or incest + Physician Certification Form
Life‑threatening maternal condition: written documentation detailing impact on mother's condition

Background

Termination of pregnancy is defined in this policy as the elective elimination of a pregnancy. Medicaid-funded terminations are restricted by federal law (the Hyde Amendment) and Rhode Island guidance to specific circumstances — namely when the pregnancy is a result of rape or incest or when continuation of the pregnancy threatens the life of the mother. For patients who are less than 22 weeks gestation, termination is a clinical option when one of these criteria is met, and applicable documentation requirements for Medicaid-funded terminations must be followed.