CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Therapy Authorization Request Form (PT/OT/ST)

A utilization management form for requesting prior authorization for physical therapy (PT), occupational therapy (OT) or speech therapy (ST) services from Neighborhood Health Plan of Rhode Island. It collects member, provider, clinical, and service-detail information and lists required supporting documentation to be submitted for authorization review.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyTherapy Authorization Request Form (PT/OT/ST)

Policy CodePolicy N/A

Change TypeAdministrative form (no material changes)

Effective Date

Next Review Date

Key ActionProviders must return the completed Therapy Authorization Request Form to Neighborhood's Utilization Management Department (fax 401-459-6023) and include initial evaluation, most recent progress notes/re-assessment, frequency & duration, home exercise program, progress toward goals, and modalities of treatment to obtain authorization.

POLICY UPDATE CHANGES

No material clinical or coverage changes; this is an administrative authorization form used to collect information for utilization review.

PT/OT/STTherapy Types Covered by Form

Fax:401-459-6023Submission Fax

RequiredSignature Requirement

Therapy Authorization Request Form (PT/OT/ST) — Overview

This is Neighborhood Health Plan of Rhode Island’s standardized authorization request form for outpatient therapy services — physical therapy (PT), occupational therapy (OT), and speech therapy (ST). The form collects member, provider, clinical, and service-detail information needed to review and authorize outpatient therapy services.

The form is designed to be submitted to Neighborhood’s Utilization Management Department (Fax: 401-459-6023) and must be signed by the treating therapist. It references Neighborhood’s Clinical Medical Policy for the detailed coverage criteria and authorization requirements.

Brief Stats

Therapy Types Covered by FormPT/OT/ST

Submission FaxFax:401-459-6023

Signature RequirementForm signature required

Scope SummaryA utilization management form for requesting prior authorization for physical therapy (PT), occupational therapy (OT) or speech therapy (ST) services from Neighborhood Health Plan of Rhode Island; collects member, provider, clinical, and service-detail information and lists required supporting documentation for authorization review.

Coverage / Purpose

Coverage stance: Informational. This document is a standardized authorization request form used to obtain prior authorization (a utilization management process) and is not itself a standalone coverage policy.

Detailed coverage criteria and benefit rules are contained in Neighborhood’s Clinical Medical Policy (available on the insurer’s website) — the form collects the clinical and service details needed for review against those policy criteria.

Form Submission and Documentation Requirements

Form Submission / Documentation Requirements

Form must be completed and signed; submit with supporting clinical documentation:

Completed Therapy Authorization Request Form returned to Utilization Management Department (Fax: 401-459-6023 or phone provided).

Form must be signed by the treating therapist.

Signature and date required.

Include initial evaluation and most recent progress notes and/or re-assessment.

Submitted documentation should include Frequency & Duration, Home Exercise Program, Progress towards goals, and Modalities of treatment.

Each item is a required element of the clinical submission.

Indicate whether member received services elsewhere in last 12 months; if yes, provide when and where.

Provide CPT code(s) and units, diagnosis and diagnosis code, dates of service, place of service, and number of requested visits and prior authorized visits.

Prior Authorization

Submit completed authorization form with required documentation

Providers must return the completed Therapy Authorization Request Form to Neighborhood's Utilization Management Department (fax 401-459-6023) and include the following required documentation to obtain authorization:

Initial evaluation
Most recent progress notes and/or re-assessment
Frequency & Duration
Home Exercise Program (HEP)
Progress toward goals
Modalities of treatment

Documentation Required

Therapist signature required

The form must be signed and dated by the treating therapist. Unsigned or undated forms may be considered incomplete for review.

Billing Rule

Provide CPT codes, units, and diagnosis codes on form

List CPT code(s) and units, diagnosis and diagnosis code, dates of service, place of service, and the number of requested visits and number of previous authorized visits on the form to enable utilization review.

Definitions

PTPhysical Therapy

OTOccupational Therapy

STSpeech Therapy

The form references Neighborhood’s Clinical Medical Policy for the detailed coverage criteria and authorization requirements and gathers required member, provider, clinical, and service information (member name/ID/DOB; therapy facility and contact; CPT code(s) and units; diagnosis and diagnosis code; dates of service; number of requested and previously authorized visits).

It also lists required supporting documentation to be submitted with the request (initial evaluation, most recent progress notes/re‑assessment, Frequency & Duration, Home Exercise Program, Progress towards goals, and Modalities of treatment) and must be signed and dated by the treating therapist.