CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Non-Surgical Interventional Pain Management Prior Authorization Form

A prior authorization request form for non-surgical interventional pain management procedures (epidural steroid injections, facet joint injections, sacroiliac injections, radiofrequency ablation, etc.) to be completed by providers and returned to Neighborhood Health Plan of Rhode Island Utilization Management for review and authorization.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyNon-Surgical Interventional Pain Management Prior Authorization Form

Policy CodePolicy N/A

Change TypeAdministrative form / billing workflow

Effective Date

Next Review Date

Key ActionProviders must return the completed, signed form with required clinical notes to Neighborhood Health Plan of Rhode Island Utilization Management to request authorization; incomplete or unsigned requests risk denial.

POLICY UPDATE CHANGES

No material clinical/coverage changes — this document is a workflow/billing prior authorization form and does not itself change clinical coverage criteria.

1Prior Authorization Form Pages

7Required Clinical Elements

Policy Overview

A prior authorization request form for non-surgical interventional pain management procedures to be completed by providers and returned to Neighborhood Health Plan of Rhode Island Utilization Management for review and authorization. The form is a workflow/billing instrument to collect member, provider, and clinical information necessary for utilization management review; it does not itself specify detailed clinical coverage criteria.

Authorization & Documentation Requirements

Documentation Required for Prior Authorization

Authorization requests must include ALL of the following clinical documentation:

Last injection / injection history
Relief from last injection
Provocative results testing
Previous physical therapy
Pain medication used
Functional impairment
Comprehensive management treatment plan for pain

Form Completion and Signature

Member and provider information: Form must be completed with member and provider information (name, ID, DOB, provider NPI, contact, date of service, place of service, ordering MD, etc.)
Anatomic location: Specify anatomic location treated
CPT codes and procedure details: Specify CPT code(s), units, levels, laterality (left/right/bilateral/unilateral), and anesthesia type (local or MAC)
Procedure requested: Indicate procedure requested (epidural steroid injection — interlaminar or transforaminal; spinal facet joint injection — diagnostic or therapeutic; sacroiliac injection; radiofrequency nerve ablation; other)

What Providers Must Do

Prior Authorization

Submit completed prior authorization form

Providers must return the completed form to Neighborhood Health Plan of Rhode Island Utilization Management Department (fax/phone provided on form) with required clinical notes to request authorization; incomplete requests risk denial.

Documentation Required

Attach supporting clinical notes

Attach clinical notes that include injection history, relief from last injection, provocative testing results, previous physical therapy, pain medications used, functional impairment, and a comprehensive pain management plan.

Billing Rule

Physician signature required

The form must be signed and dated by the treating physician; unsigned forms are not valid for authorization determination.

Documentation Required

Specify procedure details

Include anatomic location, CPT code(s), units, levels, laterality (left/right/bilateral/unilateral), anesthesia type (local or MAC), and the exact procedure requested to allow proper review and authorization.

Form Details & Workflow

Operationally, this is a one-page prior authorization request form used to collect member, provider, and clinical information for utilization management review of non-surgical interventional pain procedures. It is intended to be submitted to Neighborhood Health Plan of Rhode Island Utilization Management with supporting clinical notes for authorization review. Prior Authorization Form Pages: 1. Required Clinical Elements: 7.

Procedures listed on the form include: epidural steroid injection — interlaminar or transforaminal; spinal facet joint injection — diagnostic or therapeutic; sacroiliac injection; radiofrequency nerve ablation; and other.