This temporary policy describes Neighborhood Health Plan of Rhode Island’s Prior Authorization Waiver, enacted in response to the COVID-19 pandemic. When the State of Rhode Island declares a state of emergency due to a pandemic health concern or when Neighborhood elects to enact this policy outside a declared state of emergency, Neighborhood may temporarily remove certain prior authorization requirements for specified services during stated effective periods. The policy is separate from Neighborhood’s clinical and billing policies; other policies (for example retroactive authorization, readmission, and provider preventable condition policies) remain in effect even while this temporary policy is operative. [[0]]
The policy applies to all lines of business (Medicaid excluding Extended Family Planning (EFP), Commercial, and INTEGRITY) and to both participating and non‑participating providers. Neighborhood reserves the right to implement, modify, or terminate this temporary policy without the standard 60‑day contractual notice; any changes will be posted on Neighborhood’s COVID‑19 Provider Guidance website. [[1]]
During the initial medical waiver period April 1, 2020 – June 30, 2020, prior authorizations were not required for admissions (including transfers) occurring within the effective dates for: Inpatient acute care level of care determinations, Skilled Nursing Facilities, Inpatient Rehabilitation, and Long Term Care Facilities. Neighborhood nevertheless requires notification for all admissions and transfers and reserves the right to perform retrospective and concurrent reviews. Outpatient and pharmacy authorization processes remained in effect. [[3]]
Beginning July 1, 2020, prior authorizations were not required for non‑pharmacy COVID‑19 related diagnostic and treatment services that occurred within the effective date of the policy. [[4]]
For behavioral health services, prior authorizations were waived for both inpatient and outpatient admissions/ services occurring within the policy’s effective period; Neighborhood’s vendor requires notification for behavioral health admissions and transfers and Neighborhood reserves its audit and review rights. Providers should contact OPTUM Provider Express for the most current behavioral health details. [[5]]
Standard reimbursement rules continued to apply throughout the waiver. Neighborhood retained the right to perform retrospective claims payment audits and to request medical records to verify adherence to this policy and other applicable policies. Claims and submissions had to comply with AMA CPT, ICD‑10‑CM, and HCPCS Level II coding standards. Providers were required to submit complete claims within 90 days of the date services were provided. [[2]][[6]]
Document history shows multiple updates extending the policy effective date and clarifying implementation language; the policy effective period was extended through 12/31/2020 in the October 22, 2020 update. [[9]]