CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

In Lieu Nonpharmacologic Therapies for Chronic Pain - Coverage Criteria

Form and criteria governing authorization requests for in-lieu nonpharmacologic therapies (chiropractic, acupuncture, massage) as alternatives to medications or invasive procedures for chronic pain for Neighborhood Health Plan of RI members.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyIn Lieu Nonpharmacologic Therapies for Chronic Pain - Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionReturn a completed authorization form to Utilization Management at (401) 459-6023 including attestation and supporting clinical documentation.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3therapy types listed as in-lieu options

1utilization management return phone number

6form sections (member, provider, clinical, signature, decision)

Coverage Criteria

Authorization criteria for In-Lieu Nonpharmacologic Therapies

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Attestation: Provider attests the requested chiropractic, acupuncture, or massage therapy is an alternative to medications or invasive procedures for chronic pain.

Provider must check the box and sign the form indicating in‑lieu status

Documentation: Submission includes diagnosis and diagnosis code, procedure and procedure code, and all supporting clinical documentation.

See clinical information section of the form for required fields

Provider and service details: Form includes rendering provider name/group, provider NPI, date(s) of service, place of service, provider contact and ordering MD.

Complete provider information is required on the form

Submission: Completed form must be returned to Utilization Management for authorization processing.

Return to Utilization Management at (401) 459-6023; UM will issue an authorization number and decision with dates and services if approved

The form includes a clear payment disclaimer: "Authorization is not a guarantee of payment." Providers should note that an approved authorization does not ensure reimbursement and must submit complete billing and clinical documentation in accordance with payer requirements. The form does not list any specific conditions or scenarios that are designated as not medically necessary.

Provider Actions & Submission Requirements

Prior Authorization

Authorization form submission — Prior Authorization Required

Prior authorization request: Please return the completed authorization form to the Utilization Management Department at (401) 459-6023. UM will review and issue an authorization number if approved.

Return completed form to Utilization Management at (401) 459-6023.
UM will issue an authorization number and notify the provider; denied requests will receive a not-approved letter.

Documentation Required

Required submission information — Documentation Required

Request must include all required provider and member information and dates of service plus supporting clinical documentation. Include the rendering provider/group name, provider/group NPI, date request sent, date(s) of service, previous authorization number (if any), place of service or facility (city/town), provider contact name and phone, and ordering MD.

Required: Rendering provider/group name and NPI.
Required: Date request sent and date(s) of service.
Include previous authorization number if applicable.
Include place of service (city/town) or facility.
Include provider contact name and phone number and ordering MD.
Attach all supporting clinical documentation (see Clinical Information callout).

Documentation Required

In‑lieu attestation — Documentation Required

When requesting chiropractic, acupuncture, or massage therapy as an in‑lieu service, the request must include an attestation signed by the treating physician or licensed provider stating that the requested in‑lieu service is being used as an alternative to medications or invasive procedures for chronic pain.

Attestation must be signed and dated by the treating physician or licensed provider.
Specify which modality is requested in lieu of medications or invasive procedures (chiropractic, acupuncture, or massage therapy).

Background

This authorization form supports use of nonpharmacologic therapies — specifically chiropractic, acupuncture, and massage therapy — when they are requested as alternatives to medications or invasive procedures for chronic pain management. Providers are required to include diagnosis and procedure codes and to attest on the form that the requested service is an in‑lieu alternative to standard pharmacologic or invasive treatments; supporting clinical documentation should be attached to justify the request.

Definitions

In‑Lieu Nonpharmacologic Therapies (definitions)

Defined in-lieu therapiesChiropractic services, acupuncture services, and massage therapy provided as alternatives to medications or invasive procedures for chronic pain.

ScopeApplied when these nonpharmacologic therapies are requested instead of standard medication or invasive treatment options for chronic pain.

Attestation requirementProvider must check the box and sign the form attesting the requested service is an In Lieu of Service (alternative to medications or invasive procedures).

Documentation linkageThese therapies are listed on the clinical information section which requests diagnosis, procedure codes, and supporting documentation.

Frequency Limits

Frequency limits

Authorization response fieldsAuthorization number, dates of service, services approved, UM initials, and notification date provided on Neighborhood Decision section.

Decision outcomeNot approved cases are followed by a 'Not Approved Letter to Follow' entry on the Neighborhood Decision form section.

No numeric frequency limits listedThe form does not specify numeric visit or time-based frequency limits for chiropractic, acupuncture, or massage therapy.