RetiredNeighborhood Health Plan of Rhode IslandPolicy N/A

Temporary Prior Authorization Policy

Governs temporary suspension of certain prior authorization requirements for Neighborhood Health Plan of Rhode Island members and providers during a declared state of emergency or when Neighborhood elects to enact it; applies to most lines of business and participating and non‑participating providers.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyTemporary Prior Authorization Policy (temporary removal of certain prior authorization requirements)

Policy CodePolicy N/A

Change TypeTemporary removal of prior authorization

Effective DateApr 1, 2020

Next Review DateN/A

Key ActionDo not require prior authorizations for listed inpatient and facility services for admissions/transfers occurring between April 1 and April 30, 2020; providers must still notify Neighborhood of all admissions and transfers.

SourceLink

POLICY UPDATE CHANGES

Temporarily removed prior authorization requirements for specified inpatient and facility services from April 1, 2020 through April 30, 2020.

Apr 1–Apr 30, 2020Policy effective date range

90 daysClaim filing timeframe

Most lines (excl. EFP)Applicable lines of business

Participating & non-participating

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Temporary Coverage Criteria During Effective Window

Medical Prior Authorization Exceptions

Covered when ALL of the following are met:

ALL of the following

ONE of
- Inpatient Acute Care level of care determinations
- Skilled Nursing Facilities
- Inpatient Rehabilitation
- Long Term Care Facilities
Admission date (including transfer date) occurs within the policy effective dates
Notification to Neighborhood is required for all admissions and transfers
Neighborhood reserves the right to perform retrospective and concurrent reviews.

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Behavioral Health Prior Authorization Exceptions

Covered when ALL of the following are met:

ALL of the following

ONE of
- Inpatient behavioral health
- Outpatient behavioral health
Admission date (including transfer date) occurs within the policy effective dates
Vendor notification to Neighborhood is required for all admissions and transfers
Neighborhood reserves the right to perform retrospective and concurrent reviews.

Claim Coding and Filing Requirements

Coding standards for claim submissionmixed

CPT/ICD-10/HCPCS

Claims must comply with CPT, ICD-10-CM, and HCPCS Level II coding standards

Claim filing timeframe

Claim filing timeframeSubmit 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.

Coding standards requirementAll submissions must comply with CPT, ICD-10-CM, and HCPCS Level II coding standards.

Provider Actions and Waivers (Temporary)

Prior Authorization

Medical Prior Authorization Waiver (April 1–30, 2020)

Prior Authorizations will not be required for the following services when the admission date (including transfer date) occurs within the effective date of this policy: Neighborhood will still require notification for all admissions and transfers. Neighborhood reserves the right to perform retrospective reviews and concurrent reviews. Outpatient and pharmacy authorization processes remain in effect.

Inpatient Acute Care level of care determinations
Skilled Nursing Facilities
Inpatient Rehabilitation
Long Term Care Facilities

Prior Authorization

Behavioral Health Prior Authorization Waiver (April 1–30, 2020)

Prior Authorizations will not be required for the following services when the admission date (including transfer date) occurs within the effective date of this policy: Neighborhood's behavioral health vendor requires notification for all admissions and transfers. Neighborhood reserves the right to perform retrospective reviews and concurrent reviews.

Scope and Definitions

Temporary Prior Authorization Policy

Policy triggerApplies when the State of Rhode Island declares a state of emergency due to a pandemic or when Neighborhood elects to enact the policy outside a declared emergency.

Temporary removal of authorizationsNeighborhood may temporarily remove certain prior authorization requirements during the policy period.

Concurrent policies remain in effectOther Neighborhood Clinical Medical and Payment Policies continue to apply (including retroactive authorization, readmission, and provider preventable condition policies).

Scope (lines of business)

Lines of business affectedApplies to all lines of business: Medicaid (excluding Extended Family Planning), Commercial, and INTEGRITY.

Provider applicability