CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Temporary Prior Authorization Waivers (Pandemic Response)

Defines when Neighborhood Health Plan of Rhode Island will temporarily waive prior authorization requirements for certain services during declared or plan-enacted pandemic emergencies; applies to Neighborhood commercial and Medicaid lines as specified. Affects providers submitting claims and seeking authorizations for services during the listed effective periods.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyTemporary Prior Authorization Waivers (Pandemic Response)

Policy CodePolicy N/A

Change TypeRevision — material reinstatement and lift of waivers

Effective DateJul 1, 2020

Next Review Date

Key ActionDo not submit prior authorization requests for listed non‑pharmacy services during the policy's specified temporary effective periods; maintain documentation and notify per admission/transfer requirements.

SourceLink

POLICY UPDATE CHANGES

Auth rules were reinstated for Medicaid and Integrity effective 10/1/21.

Per Executive Office of Health and Human Services memo, authorization waivers were lifted prior to 08/25/21.

Policy marked obsolete on 05/01/23 with direction to use Neighborhood's authorization search tool.

multipledistinct temporary effective periods listed

services listedtypes exempted from prior auth

1Provider Services phone number

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Temporary Prior Authorization Waiver Criteria

Temporary prior authorization waiver criteria

Prior authorization is waived for the following services when the admission/service date falls within the stated effective period:

Waiver periods and service groups

July 1, 2020 - Sep 30, 2021: Non-pharmacy primary COVID-19 related diagnostic and treatment services waived.dates inclusive
Pharmacy Authorization processes remain in effect
Apr 1, 2020 - Jun 30, 2020: Inpatient acute care level of care determinations, skilled nursing facilities, inpatient rehabilitation, and long term care facility prior authorizations waived; Neighborhood requires notification for admissions/transfers and reserves the right to retrospective and concurrent reviews.dates inclusive
Outpatient and Pharmacy Authorization processes remain in effect
Dec 1, 2020 - Jun 9, 2021: Inpatient acute care determinations, skilled nursing facilities, inpatient rehabilitation, long term care facilities, in‑patient COVID-19 treatment in out-of-network facilities, and non‑pharmacy COVID-19 diagnostic and treatment services waived; Neighborhood requires notification for admissions/transfers and reserves the right to retrospective and concurrent reviews.dates inclusive
Pharmacy Authorization processes remain in effect
June 10, 2021: Non-pharmacy primary COVID-19 related diagnostic and treatment services waived.dates inclusive
Pharmacy Authorization processes remain in effect
July 1, 2020 - Nov 30, 2020: Non-pharmacy COVID-19 related diagnostic and treatment services waived.dates inclusive
Pharmacy Authorization processes remain in effect
Apr 1, 2020 - Jun 9, 2021 (Behavioral Health): Primary COVID-19 related behavioral health services (inpatient and outpatient) prior authorizations waived; vendor requires notification for admissions/transfers and Neighborhood reserves the right to retrospective and concurrent reviews.dates inclusive
Contact OPTUM Provider Express for behavioral health specifics

Pharmacy authorizations remain in effect and are not waived under this policy.applies to all periods

Pharmacy authorizations remain in effect and are not waived under this policy. Even when prior authorization requirements for specified non‑pharmacy services are temporarily suspended for the effective periods listed in this policy, providers must follow existing pharmacy authorization processes for medications.

All services must be medically necessary to qualify for reimbursement. Neighborhood may use Local Coverage Determinations (LCDs), National Coverage Determinations (NCDs), industry‑accepted criteria such as InterQual, recommendations from the Rhode Island Executive Office of Health and Human Services (EOHHS), and Neighborhood Clinical Medical Policies to determine medical necessity. Providers retain responsibility to verify eligibility, coverage, and any authorization criteria prior to rendering services.

Coding Standards and Code References

Coding standards referencedmixed

CPT	References to CPT as coding standard (no specific CPT codes listed)
ICD-10-CM	References to ICD-10-CM as coding standard (no specific diagnosis codes listed)
HCPCS	References to HCPCS Level II as coding standard (no specific HCPCS codes listed)

Provider Responsibilities and Operational Notes

Prior Authorization

Temporary waivers of prior authorization

During temporary waiver periods listed below, Neighborhood will not require prior authorization for specified services that occur within the stated effective dates. Pharmacy authorization processes remain in effect unless explicitly noted. Providers must still notify Neighborhood of admissions and transfers where required and should be aware that claims remain subject to contractual rules, timely filing, and retrospective or concurrent review by Neighborhood.

Effective April 1, 2020 through June 30, 2020: No prior authorization required for inpatient acute care level of care determinations, skilled nursing facilities, inpatient rehabilitation, and long term care facilities. Notification required for all admissions/transfers; outpatient and pharmacy authorizations remain in effect.
Effective April 1, 2020 through June 9, 2021: No prior authorization required for primary COVID-19 related behavioral health services (inpatient and outpatient). Vendor notification required for admissions/transfers; retrospective and concurrent reviews reserved.
Effective July 1, 2020 through September 30, 2021: No prior authorization required for non-pharmacy primary COVID-19 related diagnostic and treatment services. Pharmacy authorization processes remain in effect.
Effective July 1, 2020 through November 30, 2020: No prior authorization required for non-pharmacy COVID-19 related diagnostic and treatment services. Pharmacy authorization processes remain in effect.
Effective December 1, 2020 through June 9, 2021: No prior authorization required when admission date (including transfer date) occurs within the period for inpatient acute care determinations, skilled nursing facilities, inpatient rehabilitation, long term care facilities, in‑patient COVID-19 treatment in out-of-network facilities, and non-pharmacy COVID-19 related diagnostic and treatment services. Notification required for admissions/transfers; pharmacy authorizations remain in effect.

Key Definitions

Medical necessity

DefinitionServices must meet medical necessity to qualify for reimbursement as determined using Local Coverage Determinations (LCDs), National Coverage Determinations (NCDs), industry-accepted criteria (e.g., InterQual), Rhode Island EOHHS recommendations, and Neighborhood's Clinical Medical Policies.

Scope of applicationApplies when Neighborhood elects to enact this temporary prior authorization policy or when the State of Rhode Island declares a pandemic-related state of emergency; does not replace or modify other Clinical Medical Policies or payment policies.

Provider responsibilityProviders are responsible for verifying member eligibility, coverage, and authorization criteria and for ensuring billed services meet medical necessity requirements.

Documentation standardMedical record documentation must support billed services and medical necessity and is subject to Neighborhood's audit and review processes.

Determination resourcesNeighborhood may rely on LCDs, NCDs, InterQual, EOHHS recommendations, and its Clinical Medical Policies when determining medical necessity.

Policy Background

This policy is a temporary administrative measure implemented to remove prior authorization barriers for specified services during declared pandemic emergencies or when Neighborhood elects to enact the measure. It does not change clinical medical policies or standards of care; services must still meet medical necessity and be supported by appropriate documentation. The policy lists multiple distinct effective periods during which prior authorization requirements for certain non‑pharmacy COVID‑19 diagnostic, treatment, inpatient, skilled nursing, rehabilitation, long‑term care, and behavioral health services were suspended, while pharmacy authorizations and notification requirements for admissions/transfers remained in effect.

Document History and Changes

2023-05-01administrative

Policy marked obsolete with direction to refer to Neighborhood's authorization search tool.

2021-10-01reinstatementLatest

Authorization rules reinstated for Medicaid and Integrity effective 10/1/21.

2021-08-25regulatory_update