CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Behavioral Health Services Prior Authorization Form

This form governs prior authorization requests for behavioral health services provided to Neighborhood Health Plan of Rhode Island members, including out-of-network, non-covered, and administratively necessary days. It affects providers requesting authorization and the UM department processing requests.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyBehavioral Health Services Prior Authorization Form

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit the completed prior authorization form with required clinical documentation and W-9 (if not previously provided) for out-of-network, non-covered, or administratively necessary days.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1required form for OON/non-covered/administrative-day requests

~30listed outpatient/inpatient behavioral services on form

W-9payment requirement: W-9 needed for reimbursement

1fax number for UM department

Coverage & Authorization Criteria

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

General authorization criteria

Services listed on the form are subject to authorization when requested; providers must supply clinical justification and documentation.

Authorization submission requirements: Submit the completed prior authorization form and attach required clinical documentation (MD orders, physician office notes, consults, evaluations, diagnostic testing results, previous treatment outcomes, and other patient clinical information). Include member and provider details. For out‑of‑network (OON) requests provide the reason for OON referral and supporting documentation from an in‑network provider. If medications are associated with the request, fax to Pharmacy at 1-844-639-7906. Submit W-9 if applicable for payment.

Failure to provide sufficient clinical documentation will delay processing or result in return of the request.

Submit prior authorization requests using the Behavioral Health Services Prior Authorization Form only for out-of-network (OON) services, non-covered services, and for administratively necessary days (e.g., boarding or lack of a safe discharge plan). Do not use this form for routine in‑network services. Return the completed form and all required documentation to Utilization Management via the phone or fax number listed on the form.

The form does not list specific non‑medically necessary (NMN) conditions; determinations that a request is not medically necessary will be made by Utilization Management based on the clinical documentation submitted with the request. Ensure clinical notes and supporting records are attached to allow UM to evaluate medical necessity.

What Providers Must Do

Prior Authorization

Prior Authorization Required

Prior authorization is required for out-of-network services, non-covered services, and administratively necessary days (for example, lack of a safe discharge plan or placement). Submit requests for OON, non-covered, and administratively necessary days with clinical justification explaining the medical necessity for the requested service or day.

Submit completed Behavioral Health Services Prior Authorization Form to Utilization Management at (401) 459-6023.
Include clear clinical rationale for why in-network care is not appropriate or available.
For boarding/administratively necessary days, explain discharge barriers and placement efforts.

Note

Provider Instructions

ATTENTION: Complete all fields on the authorization form and submit all clinical documents requested. Provide reason for out-of-network referral and supporting documentation from the in-network provider when applicable.

Attach MD orders, physician office notes, consults, evaluations, and previous treatment outcomes.
Include results of diagnostic testing and any relevant psychiatric/behavioral assessments.
If medications/pharmaceuticals are part of the request, fax related information to Pharmacy at 1-844-639-7906.

Documentation Required

Required Clinical Documentation

Include all relevant clinical documentation with the request to allow timely processing. Failure to provide sufficient documentation may result in returned, delayed, or denied authorizations.

Attach MD orders, office notes, consults, evaluations, and prior treatment history.
Include diagnostic testing results and psychiatric/psychological assessments.
For ASAM or specialized services (e.g., ABA, ECT, TMS, PHP, SUD residential levels), include service-specific assessments and placement criteria.

Billing Rule

Payment Documentation

A completed W-9 form is required for payment if Neighborhood Health Plan of Rhode Island has not previously received one. Submit the W-9 with the authorization request to ensure timely reimbursement for authorized services.

If the provider has not previously submitted a W-9 to NHPRI, include it with this request.
Ensure W-9 reflects the payee name and taxpayer identification used for billing.

Denial Risk

Insufficient Documentation May Delay or Deny Request

Failure to provide sufficient clinical documentation or required forms (e.g., W-9) may result in denial, returned requests, or incomplete processing and delays in authorization. Ensure all requested fields on the form are completed and all supporting documents are attached.

Incomplete forms or missing clinical records may be returned without review.
Missing W-9s can delay payment even if the service is authorized.
Resubmissions should include the previously requested missing documents to avoid repeated delays.

Levels of Care Covered / Assessed

Multiple levels (Outpatient, IOP, PHP, Inpatient, Residential, SUD/ASAM levels)

Level-specific authorization and medical necessity must be justified in the clinical documentation attached to the request.

Level of care selection: Specify the requested level of care on the form (examples listed include Outpatient, Intensive Outpatient, Partial Hospitalization, Inpatient acute hospitalization, Acute Residential Treatment, Residential SUD per ASAM 3.1/3.3/3.5, crisis stabilization/observation, and other listed levels).

Clinical notes must support admission criteria for the selected level and continued stay requests.

Modalities & Service Types

Listed modalities

The form lists specific treatment modalities and services that may require authorization; indicate the modality and attach supporting clinical information.

Listed modalities: Select and document the modality requested (examples on the form include Applied Behavioral Analysis (ABA), Electro‑Convulsive Therapy (ECT), Transcranial Magnetic Stimulation (TMS), Partial Hospitalization (PHP), Intensive Outpatient Treatment (IOP), Home Based Treatment Services (HBTS), ASAM SUD residential levels 3.1/3.3/3.5, inpatient services, crisis stabilization/observation, medication‑related services routed to Pharmacy when medications are associated).

If medications are associated, fax request to Pharmacy Department at 1-844-639-7906. For any 'Other Service' selected, provide specific service details in the form field.

Key Definitions

Administratively Necessary Days — definition and when to request

DefinitionAdministratively Necessary (Lack of a safe discharge plan/placement) Days: days requested because the member lacks a safe discharge plan or placement.

When to requestRequest when a member is medically ready for discharge but no safe discharge plan, placement, or bed is available (boarding/awaiting placement).

Where to documentIndicate 'Administratively Necessary' or 'Boarding Days' on the prior authorization form and provide dates of service and clinical justification.

Required supporting infoAttach clinical documentation (MD orders, physician notes, evaluations, diagnostic results, previous treatment outcomes) to justify continued stay while awaiting placement.

Processing noteFailure to provide sufficient information may delay the request or result in return of the request to the provider.

Visit Limits & Administrative Requests

Administratively Necessary (boarding/lack of safe discharge) days — submission via form

Form requirementAdministratively Necessary (boarding/lack of safe discharge) days must be requested using this Behavioral Health Services Prior Authorization form.

Form fields to completeInclude Authorization # (if any), Dates of Service, Services Approved, and UM contact details on the form; mark 'Boarding Days' or the 'Administratively Necessary' line as applicable.

Submission instructionsReturn the completed form to the Utilization Management Department via the contact/fax information provided on the form; include all clinical documents.

Clinical documentationAttach MD orders, physician office notes, consults, evaluations, diagnostic testing results, and previous treatment outcomes as listed on the form.

Background & Scope

This authorization form supports requests across the behavioral health continuum, including outpatient therapies, Intensive Outpatient (IOP), Partial Hospitalization (PHP), acute inpatient hospitalization, residential programs (including ASAM SUD residential levels 3.1, 3.3, 3.5), crisis stabilization, Applied Behavioral Analysis (ABA), Electro‑Convulsive Therapy (ECT), Transcranial Magnetic Stimulation (TMS), Home Based Treatment Services (HBTS), and medication‑related services routed to pharmacy when medications are involved. The form also covers requests for Administratively Necessary (boarding/lack of safe discharge) days and other specialty services listed on the form.

Primary Diagnosis Code(s)	Field on form to provide ICD-10 or diagnosis codes
Procedure Code(s)	Field on form to provide CPT/HCPCS or procedure codes

OpenPayer