Executive Office Of Health And Human Services Coverage Criteria
- Executive Office Of Health And Human Services prior authorization
- All Executive Office Of Health And Human Services policy updates
Latest Executive Office Of Health And Human Services coverage criteria updates25
- Coverage CriteriaAdministrative/Operational PolicyEff. 2023-07-01Rhode Island EPSDT periodicity schedule (table of contents excerpt)Part of the EOHHS contract materials (amended July 1, 2023); this excerpt contains the table of contents, definitions, and header pages — no explicit coverage criteria in this window.All Executive Office of Health and Human Services updates
- Coverage CriteriaAdministrative/Operational PolicyEff. 2022-07-01Neighborhood Health Plan of Rhode Island Amendment No. 8Amendment No. 8 modifies the Agreement between the Rhode Island Executive Office of Health and Human Services and Neighborhood Health Plan of Rhode Island governing Medicaid managed care services, including program standards, fee schedules, benefits (doula services), and contractor capitations for SFY2023; it affects the State (EOHHS) and the Contractor (NHPRI).All Executive Office of Health and Human Services updates
- Coverage CriteriaClinical/Medical PolicyEff. 2021-10-01Pharmacy & Therapeutics Committee - PDL Formulary Recommendations (Coverage Criteria)Summarizes P&T committee recommendations and formulary changes for multiple therapeutic drug classes that affect Medicaid pharmacy preferred status and utilization management; intended for pharmacy/program administrators and providers interacting with the Medicaid PDL.All Executive Office of Health and Human Services updates
- Coverage CriteriaClinical/Medical PolicyEff. 2016-07-01Personal Assistance Services and Supports (PASS) practice standardsRequirements and practice standards for providers delivering Personal Assistance Services and Supports (PASS) to Medicaid-eligible children and adolescents in Rhode Island, including eligibility, prior approval, clinical criteria, service planning, and provider responsibilities.All Executive Office of Health and Human Services updates
- Coverage CriteriaClinical/Medical PolicyEff. 2016-01-01Personal Assistance Services and Supports (PASS) Practice StandardsStandards governing certification, delivery, prior approval, clinical criteria, and service planning for PASS for Medicaid-eligible children and adolescents in Rhode Island; affects PASS provider agencies, clinical consultants, direct service workers, families and guardians.All Executive Office of Health and Human Services updates
- Coverage CriteriaClinical/Medical PolicyAugmentation Mammoplasty (Breast Enlargement) Coverage CriteriaDefines coverage and prior authorization requirements for augmentation mammoplasty (breast enlargement) including use of autogenous tissue or implants; applies to members covered by the Executive Office of Health and Human Services.All Executive Office of Health and Human Services updates
- Coverage CriteriaClinical/Medical PolicyBariatric Surgery Coverage CriteriaGoverns medical necessity criteria, prior authorization, and coverage for bariatric (weight-loss) surgical procedures including primary and revision surgeries for members with severe or morbid obesity. Affects providers requesting authorization and recipients seeking bariatric surgery through the Executive Office of Health and Human Services.All Executive Office of Health and Human Services updates
- Coverage CriteriaClinical/Medical PolicyBiomarker Testing — Coverage CriteriaDefines coverage and payment conditions for biomarker testing for beneficiaries of the Executive Office of Health and Human Services, specifying clinical documentation and prior authorization requirements that affect ordering providers and laboratories.All Executive Office of Health and Human Services updates
- Coverage CriteriaClinical/Medical PolicyCoverage Criteria — KYMRIAH® (tisagenlecleucel) and YESCARTA™ (axicabtagene ciloleucel)Medicaid FFS coverage criteria, limitations, and facility requirements for FDA-approved CAR-T therapies KYMRIAH® (tisagenlecleucel) and YESCARTA™ (axicabtagene ciloleucel). Applies to members seeking those therapies under the Executive Office of Health & Human Services Medicaid FFS program.All Executive Office of Health and Human Services updates
- Coverage CriteriaClinical/Medical PolicyDRAFT Drug Utilization Review (DUR) Board Meeting Minutes — Coverage Criteria (pharmacy program activities)Draft minutes documenting DUR Board discussions and recommendations about pharmacy program activities (lock-in program, prescriber outreach, opioid and antipsychotic utilization, low-dose quetiapine, non-preferred/high-cost drugs) that affect Rhode Island Medicaid managed care and fee-for-service medication management processes and stakeholders.All Executive Office of Health and Human Services updates
- Coverage CriteriaClinical/Medical PolicyDUR Board follow-up: monitored utilization and tracking (coverage criteria)Summarizes Drug Utilization Review Board discussions, follow-up items, utilization metrics, and tracking requests for Rhode Island Medicaid (FFS) across multiple drug categories; affects EOHHS program staff, DUR board members, pharmacy benefit managers (Gainwell, Acentra), and Medicaid providers involved in prescribing/monitoring these therapies.All Executive Office of Health and Human Services updates
- Coverage CriteriaClinical/Medical PolicyDental Services Coverage Manual — Dental services coverage for Rhode Island MedicaidDefines coverage, medical necessity criteria, provider billing rules, and scope of dental services for Rhode Island Medicaid Fee-For-Service recipients (with note that children born after May 1, 2000 may be covered under RIte Smiles managed care).All Executive Office of Health and Human Services updates
- Coverage CriteriaClinical/Medical PolicyDrug Utilization Review (DUR) Board Meeting Minutes — Coverage CriteriaSummarizes the Rhode Island EOHHS Drug Utilization Review (DUR) Board meeting discussions, utilization reviews, follow-up items, and tracking requests affecting Medicaid fee-for-service (FFS) recipients and program stakeholders.All Executive Office of Health and Human Services updates
- Coverage CriteriaClinical/Medical PolicyDrug Utilization Review (DUR) Board Meeting Minutes — Coverage Criteria (Pharmacy & Specialty Drugs)Minutes summarizing DUR findings, benchmarking, follow-up actions, and tracking decisions for pharmacy and specialty drug use in the FFS Medicaid population.All Executive Office of Health and Human Services updates
- Coverage CriteriaClinical/Medical PolicyDrug Utilization Review (DUR) Board meeting recommendations — coverage criteria for buprenorphine products, antidepressants, antipsychotics, benzodiazepines, and related interventionsMinutes of the Rhode Island DUR Board meeting summarizing safety concerns, utilization reviews, and recommended interventions for medications (notably antidepressants, citalopram/escitalopram, buprenorphine products, Suboxone/Subutex, benzodiazepines, antipsychotics, and lipid agents). Affects Medicaid prescribers, pharmacies, and program administrators.All Executive Office of Health and Human Services updates
- Coverage CriteriaClinical/Medical PolicyDrug Utilization Review (DUR) Board — Pharmacy Coverage Criteria and Program ActionsSummarizes DUR Board discussions, surveillance findings, and recommended program actions related to controlled substances, antipsychotics in children, hepatitis C agents, PDL changes, and other pharmacy utilization issues affecting Rhode Island Medicaid beneficiaries and prescribers.All Executive Office of Health and Human Services updates
- Coverage CriteriaClinical/Medical PolicyDrug Utilization Review Board meeting minutes — coverage criteria for lock-in, RDUR interventions, and pediatric psychotropic monitoringMeeting minutes documenting the DUR Board discussions about lock-in criteria, controlled substances monitoring, pediatric antipsychotic and stimulant utilization, RDUR interventions and prescriber outreach affecting Medicaid Fee-for-Service recipients, prescribers, pharmacies, and DUR administrators.All Executive Office of Health and Human Services updates
- Coverage CriteriaClinical/Medical PolicyFee for Service: Pharmacy & Therapeutics Committee Meeting Minutes — Coverage CriteriaSummarizes the September 10, 2024 Fee-for-Service Pharmacy & Therapeutics Committee meeting including attendance, therapeutic class reviews, motions, and public testimony; intended for internal stakeholders and providers affected by formulary or prior authorization changes discussed.All Executive Office of Health and Human Services updates
- Coverage CriteriaClinical/Medical PolicyHippotherapy (equine-assisted physical/occupational/speech therapy) coverage criteriaPolicy governing coverage and provider participation requirements for individually developed hippotherapy services for children with severe or developmental disabilities under Rhode Island Medicaid (EPSDT). It addresses provider certification, service delivery, billing codes, and documentation/limitations.All Executive Office of Health and Human Services updates
- Coverage CriteriaClinical/Medical PolicyPanniculectomy/Abdominoplasty coveragePolicy governs prior authorization, medical necessity criteria, documentation requirements, and non-coverage conditions for panniculectomy and abdominoplasty for beneficiaries covered by the Executive Office of Health and Human Services.All Executive Office of Health and Human Services updates
- Coverage CriteriaClinical/Medical PolicyPharmacy & Therapeutics Committee Meeting Minutes — Coverage CriteriaMinutes and decisions from the Executive Office of Health and Human Services Pharmacy & Therapeutics Committee meeting on December 12, 2018, documenting therapeutic class reviews, public testimony, committee votes, and recommendations affecting pharmacy coverage and prior authorization practices.All Executive Office of Health and Human Services updates
- Coverage CriteriaClinical/Medical PolicyPharmacy & Therapeutics Committee formulary recommendations and edits — coverage criteriaMeeting minutes documenting P&T Committee decisions on therapeutic class reviews, formulary additions/changes, step edits, and communication actions affecting Medicaid drug coverage and prior authorization processes.All Executive Office of Health and Human Services updates
- Coverage CriteriaClinical/Medical PolicyPharmacy & Therapeutics Committee — Formulary Recommendations / Coverage CriteriaQuarterly Pharmacy & Therapeutics Committee meeting minutes documenting formulary reviews, product additions/removals, and recommendations affecting the preferred drug list (PDL) and prior authorization practices for the Executive Office of Health & Human Services; intended for prescribers, pharmacists, and internal payer staff.All Executive Office of Health and Human Services updates
- Coverage CriteriaClinical/Medical PolicyPharmacy & Therapeutics Committee — PDL Recommendations and Coverage Criteria (meeting minutes)Meeting minutes documenting Pharmacy & Therapeutics Committee discussions, public testimony, and recommended changes to the Preferred Drug List (PDL) that affect Medicaid pharmacy coverage decisions and formulary placement.All Executive Office of Health and Human Services updates
- Coverage CriteriaClinical/Medical PolicyPharmacy and Therapeutics Committee Meeting Minutes - Coverage CriteriaMinutes summarizing P&T Committee attendance, therapeutic class reviews, public testimony, motions and approvals, and follow-up items affecting internal pharmacy management, formulary and DUR staff, and stakeholders monitoring P&T decisions.All Executive Office of Health and Human Services updates
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Tool Description
Search Executive Office Of Health And Human Services coverage criteria and medical necessity requirements across 21,000+ policies from 170+ payers.
Search a drug (“Wegovy”), a procedure (“knee replacement”), or a policy name, then filter by payer, specialty, policy type, or effective year. Or start from the largest publishers: UnitedHealthcare coverage criteria and Cigna coverage criteria.
Each result links the full policy page, which lists the clinical requirements, covered codes, and effective dates from the source document.
Pair a criteria search with the prior authorization lookup for approval requirements, the timely filing lookup for claim deadlines, the live policy updates feed for the newest payer publications, and payer profiles for contacts and coverage context.
FAQ
Coverage criteria are the specific clinical requirements a payer sets for covering a drug, procedure, or service: diagnoses, symptom duration, prior treatments tried, age limits, and documentation. They are published inside medical policies and clinical criteria documents, and a claim or authorization that does not meet them is denied as not medically necessary.
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