CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

In Lieu of Services (Chiropractic, Acupuncture, Massage) — Coverage Criteria

Form and authorization process for requesting 'In Lieu of Services' (chiropractic, acupuncture, massage therapy) as alternatives to medications or invasive procedures for members with chronic pain at Neighborhood Health Plan of Rhode Island.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyIn Lieu of Services (Chiropractic, Acupuncture, Massage) — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionReturn a completed In Lieu of Services form to Utilization Management (fax/phone provided) with required clinical documentation and provider attestation.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3types of in-lieu services listed on the form

1authorization decision capture section

1return fax/phone contact for Utilization Management

Coverage Criteria for In Lieu of Services

Authorization criteria for In Lieu of Services

Covered when ALL of the following are met

Attestation: Provider attests the selected In Lieu of Service is an alternative to medications or invasive procedures for chronic pain.

Provider must check the corresponding service box and sign the form.

Documentation: Form includes member information, provider information, diagnosis and procedure codes, and supporting clinical documentation.

Completed form must be returned to Utilization Management for review.

The form does not list separate medical necessity or exclusion criteria beyond the authorization requirements captured on the form. It presents the authorization logic as a set of attestation and documentation requirements that must be completed and returned to Utilization Management for review, rather than enumerating additional explicit coverage or exclusion rules.

The Neighborhood decision section on the form captures the utilization review outcome and includes a box for the reviewer to mark Not Approved - Letter to Follow, indicating a potential denial. The form does not provide specific clinical scenarios or language describing when a request would be considered not medically necessary; it only records the final Neighborhood decision.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyIn Lieu of Services (Chiropractic, Acupuncture, Massage) — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionReturn a completed In Lieu of Services form to Utilization Management (fax/phone provided) with required clinical documentation and provider attestation.

SourceLink

On This Page

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Requested Codes

Requested codes (to be provided by ordering provider)mixed

	Procedure & Procedure Code (placeholder on form — provider to supply actual CPT/HCPCS)
	Diagnosis & Diagnosis Code (placeholder on form — provider to supply ICD-10)

Provider Submission and Documentation Requirements

Prior Authorization

Authorization submission and decision documentation

Return the completed form to the Utilization Management Department at (401) 459-6023. Refer to Neighborhood's Clinical Medical Policy on www.nhpri.org for detailed information about benefits, authorization requirements, and coverage criteria.

Fax/phone submission: send completed form to Utilization Management (fax/phone above).
Neighborhood decision: Authorization section records approval/denial, authorization number, dates of service, services approved, UM initials, and notification date.

Documentation Required

Required form fields and clinical documentation

The request must include complete member, provider, and clinical information. Include supporting documentation (progress notes, relevant imaging reports, prior treatments, and medication history) to substantiate medical necessity.

Member information: Member's name, Member ID #, Member DOB.
Provider information: Rendering provider or group name, Provider/Group NPI#, Date request sent, Date of service, Previous authorization # (if applicable), Place of service (city/town)/facility, Provider contact phone #, Provider fax #, Ordering MD.
Clinical information: Diagnosis & ICD-10 code, Procedure & CPT/Procedure code, Dates of service, Relevant clinical notes and documentation supporting the request.

Documentation Required

Attestation of alternative to medications/invasive procedures

Provider must attest that the selected In Lieu of Service is being requested as an alternative to medications or invasive procedures for chronic pain and is clinically appropriate for the member.

Attestation: By checking the box and signing the form, the provider affirms that the selected service is an alternative to medications or invasive procedures for chronic pain.
Selectable In Lieu of Services: Chiropractic services, Acupuncture services, Massage therapy (each must be individually checked if applicable).

Denial Risk

Possible denial outcome

If the authorization is not approved, the form may be marked "Not Approved - Letter to Follow." Ensure contact information is complete so Neighborhood can send notifications and any denial letters.

Denial outcome: Checkbox for 'Not Approved - Letter to Follow' may be selected by UM.
Ensure provider contact and fax are included for timely notification and follow-up.

Background

This document is a provider request and attestation form to authorize In Lieu of Services — non-pharmacologic, non-invasive alternatives for chronic pain including chiropractic, acupuncture, and massage therapy. The form requires the ordering provider to supply clinical information (diagnosis and procedure codes) and to attest, by checking the appropriate box and signing, that the selected service is an alternative to medications or invasive procedures for chronic pain.

Definitions

In Lieu of Services (Definition)

DefinitionIn Lieu of Services: Chiropractic, Acupuncture, or Massage Therapy provided instead of medications or invasive procedures for chronic pain.

Services listedChiropractic Services; Acupuncture Services; Massage Therapy.

Provider attestationBy checking the box and signing, provider attests the selected service is an alternative to medications or invasive procedures for chronic pain.

Documentation requirementClinical information section requests Diagnosis & Diagnosis Code and Procedure & Procedure Code and asks for all supporting documentation.

Provider Attestation / Conservative Treatment Requirements

Frequency Limits

Frequency Limits — Chiropractic / Acupuncture / Massage

Frequency limits indicated on formNo numeric frequency limits or visit/period limits are specified on the form for chiropractic, acupuncture, or massage therapy.

Required selectionProvider must check the box for the specific service being requested (Chiropractic, Acupuncture, or Massage).

Required provider actionProvider must sign the form to attest the service is an alternative to medications or invasive procedures for chronic pain.

Imaging Requirements

Note

No imaging requirement specified on form

No imaging or other diagnostic imaging requirements are specified on the In Lieu of Services form; the form does not request imaging documentation as a condition for review.

The clinical information section requests diagnosis and procedure codes and supporting documentation but does not specify any imaging requirement.

Not Covered / Exclusions

The form does not explicitly list services that are categorically excluded or labelled as not covered. Coverage determination is driven by completion of the attestation, submission of required clinical information, and review by Utilization Management rather than by a separate not-covered list on the form itself.