CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Outpatient Rehabilitation Adult

This document is an outpatient rehabilitation (physical, occupational, speech therapy) authorization request form for Neighborhood Health Plan of Rhode Island. It collects member, provider, clinical, and service details and lists required documentation for authorization and continued visits.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyOutpatient Rehabilitation Adult

Policy CodePolicy N/A

Change TypeInformational (no material change)

Effective Date

Next Review Date

Key ActionComplete and return the form to Utilization Management at (401) 459-6023 with the initial evaluation and most recent progress notes/re-assessment including frequency & duration, home exercise program, progress toward goals, and modalities of treatment.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes for this policy/form.

3Therapy Types Supported (PT/OT/ST)

4Required Documentation Items Listed

Document overview

This is an outpatient rehabilitation authorization request form (Physical Therapy, Occupational Therapy, Speech Therapy) for Neighborhood Health Plan of Rhode Island. The form collects member and provider identification, clinical details, requested CPT codes and units, diagnosis information, and service dates to support authorization decisions.

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The form lists required documentation for initial and continued visits — including the initial evaluation, most recent progress notes and/or re-assessment, frequency & duration, home exercise program, progress toward goals, and modalities of treatment — and must be signed by the treating therapist.

Return the completed form to Neighborhood's Utilization Management Department and refer to Neighborhood's Clinical Medical Policy on the payer website for detailed benefit information, coverage criteria, and authorization requirements.

PayerNeighborhood Health Plan of Rhode Island

PolicyOutpatient Rehabilitation Adult Authorization Form

Policy NumberN/A

Effective Date

Last Review

Next Review

Scope/SummaryThis document is an outpatient rehabilitation (physical, occupational, speech therapy) authorization request form that collects member, provider, clinical, and service details and lists required documentation for authorization and continued visits.

What providers must do

Prior Authorization

Submit authorization request

Provider must complete and return the form to Utilization Management at (401) 459-6023 with initial evaluation and most recent progress notes/re-assessment; include frequency & duration, home exercise program, progress toward goals, and modalities of treatment.

Documentation Required

Required documentation for continued visits

For continued visits, submit initial evaluation, most recent progress notes and/or re-assessment and indicate therapy type (PT/OT/ST), number of requested visits, previous authorized visits, cancelled/no-shows, and whether services were received elsewhere in last 12 months.

Initial evaluation
Most recent progress notes and/or re-assessment
Therapy type (PT, OT, or ST)
Number of requested visits
Number of previously authorized visits
Number of cancelled visits or no-shows
Whether services were received elsewhere in the last 12 months

Billing Rule

Form must be signed

This form must be signed by the treating therapist; unsigned forms may not be accepted for authorization. Signature of Treating Therapist and date are required on the form.

Form coding fields

Requested Procedure Codes (form fields)CPT

No codes listed

Diagnosis Code (form field)ICD-10

No codes listed

Definitions

PTPhysical Therapy

OTOccupational Therapy

STSpeech Therapy

This form is administrative and intended to collect information for prior authorization; coverage determinations follow Neighborhood's Clinical Medical Policy available on the payer website. Coverage stance: informational.

Revision timeline

statusLatest

Document current; no revisions listed

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyOutpatient Rehabilitation Adult

Policy CodePolicy N/A

Change TypeInformational (no material change)

Effective Date

Next Review Date

SourceLink

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