RetiredNeighborhood Health Plan of Rhode IslandPolicy N/A

Temporary suspension of certain prior authorization requirements during a declared state of emergency

Governs temporary suspension of certain prior authorization requirements for providers during a declared state of emergency (or when enacted by Neighborhood); applies to participating and non‑participating providers across applicable lines of business.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyTemporary prior authorization suspension during a declared state of emergency

Policy CodePolicy N/A

Change TypeClarified effective periodadministrative date extension noted

Effective DateSee document (tied to Executive Order/through 7/1/2020)

Next Review Date

Key ActionDo not submit prior authorization requests for covered inpatient and behavioral health admissions that occur during the policy period; notify Neighborhood (or vendor) of all admissions and transfers.

SourceLink

POLICY UPDATE CHANGES

Policy effective period tied to Executive Order 20-29 and OHIC Bulletin 2020-03, remaining in effect through the earlier of July 1, 2020 or expiration of the Executive Order.

Extended policy effective date noted in Document History (04/28/20) to align with Executive Order and OHIC Bulletin.

90 daystimeframe to submit complete claims

through 7/1/2020temporary policy effective period

All linesapplies to

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Services Temporarily Not Requiring Prior Authorization

Medical inpatient waivers

Medical inpatient services for which prior authorization is not required during the policy period:

ALL of the following

ONE OF
- Inpatient Acute Care level of care determinations
- Skilled Nursing Facilities
- Inpatient Rehabilitation
- Long Term Care Facilities
Notification of all admissions and transfers to Neighborhood is required; Neighborhood reserves the right to perform retrospective and concurrent reviews.
Outpatient and pharmacy authorization processes remain in effect and are not suspended by this policy.

Behavioral health waivers

Behavioral health services for which prior authorization is not required during the policy period:

ALL of the following

ONE OF
- Inpatient behavioral health services
- Outpatient behavioral health services
Neighborhood's behavioral health vendor requires notification for all admissions and transfers; Neighborhood reserves the right to perform retrospective and concurrent reviews.

Coding and Claim Filing Details

Coding standardsmixed

CPT	Coding must meet standards defined by the AMA CPT codebook
HCPCS	HCPCS Level II coding standards apply

Claim submission window

Claim submission timeframeProviders must submit complete claims for payment within 90 days of the date services are provided to members.

Adjustments and correctionsAdjustments, corrections, and reconsiderations must include the required forms.

Standards complianceAll submissions must comply with National Claims Standards.

Provider Responsibilities and Notifications

Prior Authorization

Medical inpatient prior auth suspended — notification required

Prior authorizations will not be required for inpatient acute care level of care determinations, skilled nursing facility, inpatient rehabilitation, and long term care facility admissions when the admission (including transfer) date occurs within the policy effective period. Providers must notify Neighborhood of all admissions and transfers; Neighborhood reserves the right to perform retrospective and concurrent reviews.

Notification of all admissions and transfers to Neighborhood is required even when prior authorization is not required.

Prior Authorization

Behavioral health prior auth suspended — vendor notification required

Prior authorizations will not be required for behavioral health inpatient and outpatient services when the admission (including transfer) date occurs within the policy effective period. Neighborhood's behavioral health vendor requires notification for all admissions and transfers; Neighborhood reserves the right to perform retrospective and concurrent reviews.

Behavioral health vendor notification for all admissions and transfers is required.

Scope and Notification Definitions

Scope

Lines of business coveredMedicaid excluding Extended Family Planning (EFP), Commercial, and INTEGRITY.

Provider applicabilityApplies to Neighborhood participating and non‑participating providers.

Policy contextTemporary policy enacted in response to a pandemic state of emergency or at Neighborhood's discretion; effective period tied to Executive Order 20-29 and OHIC Bulletin 2020-03 through the earlier of July 1, 2020 or the expiration of the Executive Order.

Notification requirement

Notification requirement (medical)Providers must notify Neighborhood of all admissions and transfers even when prior authorization is not required; Neighborhood may perform retrospective and concurrent reviews.

Notification requirement (behavioral health)