Executive Office Of Health And Human Services Prior Authorization Lookup
- Executive Office Of Health And Human Services coverage criteria
- All Executive Office Of Health And Human Services policy updates
Latest Executive Office Of Health And Human Services prior authorization updates25
- Prior AuthAdministrative/Operational PolicyEff. 2026-04-01Updates to Third-Party Liability (TPL) claims processing systemThis document governs updates to Rhode Island EOHHS's TPL claims processing rules that implement federal CAA 2022 requirements, affecting providers submitting Medicaid Fee-for-Service claims when another insurer denied payment for lack of prior authorization.All Executive Office of Health and Human Services updates
- Prior AuthClinical/Medical PolicyEff. 2022-01-01Treatment of Hepatitis C Prior Authorization GuidelinesRules governing prior authorization, preferred and non-preferred hepatitis C antiviral medications, and documentation requirements for Rhode Island Medicaid beneficiaries and enrolled prescribers.All Executive Office of Health and Human Services updates
- Prior AuthAdministrative/Operational PolicyEff. 2021-12-31Prior Authorizations Suspension for Hospital-to-Nursing TransfersTemporary suspension of Medicaid managed care prior authorization requirements for members transitioning from hospitals to nursing facilities in Rhode Island, affecting Rhode Island Medicaid Managed Care Organizations (MCOs) and applicable discharges during the suspension period.All Executive Office of Health and Human Services updates
- Prior AuthAdministrative/Operational PolicyEff. 2021-12-31Suspension of prior authorization for hospital-to-nursing facility transfersTemporary suspension of Medicaid managed care prior authorization requirements for members transitioning from hospitals to nursing facilities in Rhode Island; applies to Medicaid Managed Care Organizations (MCOs).All Executive Office of Health and Human Services updates
- Prior AuthClinical/Medical PolicyEff. 2021-08-01Treatment of Hepatitis C — Prior Authorization GuidelinesRhode Island Medicaid prior authorization guidelines for pharmacologic treatment of Hepatitis C, detailing eligibility, required documentation, preferred and non-preferred agents, and continuity of treatment rules for beneficiaries and enrolled prescribers.All Executive Office of Health and Human Services updates
- Prior AuthAdministrative/Operational PolicyEff. 2021-06-30Reinstatement of Prior Authorization RequirementsThis document announces reinstatement of Medicaid prior authorization (PA) requirements in Rhode Island: non-behavioral health PAs resume October 1, 2021 and behavioral health PAs resume January 1, 2022, and it directs MCOs and providers to follow EOHHS PA rules.All Executive Office of Health and Human Services updates
- Prior AuthClinical/Medical PolicyEff. 2017-09-25General Approval Criteria — Hepatitis C medications (ADAP formulary)Prior authorization requirements and approval criteria for Hepatitis C direct-acting antiviral and related medications on the Rhode Island ADAP formulary, affecting prescribers and ADAP beneficiaries seeking HCV treatment.All Executive Office of Health and Human Services updates
- Prior AuthClinical/Medical PolicyEff. 2016-07-01Certification Standards Providers of Home Based Therapeutic Services (inclusive of ABA)Standards governing certification, scope, service components, prior authorization, and provider requirements for Home Based Therapeutic Services (HBTS) — inclusive of Applied Behavior Analysis (ABA) — as issued by the Rhode Island Executive Office of Health and Human Services. Affects HBTS provider-agencies, licensed supervisors, home-based workers, and payers administering Medicaid and applicable third-party coverage in Rhode Island.All Executive Office of Health and Human Services updates
- Prior AuthClinical/Medical PolicyEff. 2016-01-01Certification Standards for Providers of Home Based Therapeutic Services (HBTS) (inclusive of ABA)Certification standards governing provision, scope, service components, prior authorization, and provider requirements for HBTS (inclusive of ABA) for children and adolescents with moderate to severe special health care needs in Rhode Island; applies to EOHHS-certified provider-agencies and Medicaid-enrolled clients.All Executive Office of Health and Human Services updates
- Prior AuthClinical/Medical PolicyEff. 2007-12-12Drug Utilization Review (DUR) Board meeting decisions and recommendationsMinutes from the DUR Board describing PDL decisions, proposed quantity limits, prior authorization practices, data review requests, and programmatic initiatives affecting Medicaid pharmacy management in Rhode Island.All Executive Office of Health and Human Services updates
- Prior AuthAdministrative/Operational PolicyAppendix J — Window Replacement and Spot Repair/Removal Prior Authorization Form and WorksheetAppendix J provides the prior authorization form and worksheet for window replacement and spot repair/removal related to lead remediation activities; includes title, ownership, and table of contents headings for certification standards and the Lead Center program, affecting providers and administrators in Rhode Island's lead remediation program.All Executive Office of Health and Human Services updates
- Prior AuthClinical/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
- Prior AuthClinical/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
- Prior AuthClinical/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
- Prior AuthAdministrative/Operational PolicyBorder community provider status for Rhode Island MedicaidDefines which named border communities are treated as in-state providers for the Rhode Island Medicaid Program and are therefore exempt from out-of-state service restrictions and prior authorization requirements.All Executive Office of Health and Human Services updates
- Prior AuthAdministrative/Operational PolicyCertification Standards: Personal Assistance Services and Supports (PASS)Certification standards and operational requirements for agencies providing consumer-directed Personal Assistance Services and Supports (PASS) to Medicaid-eligible Children with Special Health Care Needs in Rhode Island; describes certification, service components, prior authorization, and agency responsibilities.All Executive Office of Health and Human Services updates
- Prior AuthClinical/Medical PolicyDermabrasionPolicy governing coverage and prior authorization requirements for dermabrasion procedures, primarily when performed on the face, for members of the Executive Office of Health and Human Services.All Executive Office of Health and Human Services updates
- Prior AuthClinical/Medical PolicyDrug Utilization Review (DUR) Board Meeting Minutes (Draft)Draft minutes from a DUR Board meeting summarizing utilization reviews, committee recommendations, monitoring activities, and requests for data analysis that affect Medicaid pharmacy management and prior authorization practices.All Executive Office of Health and Human Services updates
- Prior AuthClinical/Medical PolicyDrug Utilization Review (DUR) Board Meeting Minutes — Pharmacy Utilization and Prior Authorization UpdatesMinutes documenting DUR Board recommendations on medication safety and utilization affecting Medicaid medication management, including prior authorization and step therapy changes for long acting oxycodone and requests for patient-level reports.All Executive Office of Health and Human Services updates
- Prior AuthClinical/Medical PolicyDrug Utilization Review (DUR) Board meeting recommendations and utilization reviewsMinutes of the DUR Board meeting detailing utilization reviews, proposed prior authorization edits, lock-in program patient reviews, and surveillance recommendations affecting Rhode Island Medicaid pharmacy management and prescribers.All Executive Office of Health and Human Services updates
- Prior AuthClinical/Medical PolicyDrug Utilization Review Board Meeting Findings and RecommendationsMinutes from the Rhode Island DUR Board meeting summarizing reviews of drug class utilization, retrospective DUR interventions, and program updates affecting Medicaid pharmacy management and prior authorization considerations.All Executive Office of Health and Human Services updates
- Prior AuthClinical/Medical PolicyDrug Utilization Review Board — DUR meeting decisions (atypical antipsychotic PDL and utilization evaluations)Summarizes DUR Board meeting minutes detailing utilization reviews, recommendations for drug classes and products, prior authorization and preferred drug list decisions, and monitoring actions affecting Medicaid pharmacy management.All Executive Office of Health and Human Services updates
- Prior AuthClinical/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
- Prior AuthClinical/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
- Prior AuthClinical/Medical PolicyPharmacy & Therapeutics Committee - Formulary and Prior Authorization Decisions (April 5, 2011)Summarizes Pharmacy & Therapeutics Committee decisions about preferred/non-preferred status, formulary changes, and prior authorization considerations that affect Rhode Island Medicaid drug coverage and pharmacy administration.All Executive Office of Health and Human Services updates
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Tool Description
Search Executive Office Of Health And Human Servicesprior authorization policies by drug name, procedure, or policy title. Results include any policy that mentions prior authorization requirements (drug coverage criteria, imaging guidelines, site-of-service rules) not just documents titled “prior authorization.” Every result links to a full policy page with clinical criteria, covered billing codes, documentation requirements, and effective dates.
Filter by payer, specialty, policy type, or effective year; or search directly for a drug (“Wegovy,” “Ozempic”), a procedure (“MRI,” “knee arthroplasty”), or a policy number.
Coverage spans 110+ payers. Jump straight to the busiest prior-auth publishers: UnitedHealthcare, Cigna, Aetna, Anthem, and Centene. You can also browse the full policy updates feed.
Pair a prior-auth search with the billing code lookup to confirm the CPT or J-code on the claim, the payer lookup for plan footprint, and payer profiles for contacts and coverage context.
FAQ
Type a drug name (“Wegovy,” “Ozempic”), a procedure (“MRI,” “knee”), or a policy title into the search bar. Filter results by payer, specialty, policy type, or effective year. Open any result for the full policy page with clinical criteria, covered billing codes, documentation requirements, and effective dates.
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