Prior Authorization

What is Prior Authorization?

Prior Authorization is a request to get approval from Neighborhood before receiving treatment. The review process and determination is based on medical necessity. We will review the information submitted including medical records. If we need additional information we may contact your provider. 

What services require Prior Authorization?

To check if a service requires Prior Authorization contact Member Services at 1-844-812-6896 (TTY 711), 8 am to 8 pm, Monday – Friday; 8 am to 12 pm on Saturday. You may also check if a service or code is covered by going to the Prior Authorization Reference Guide page, then click on the ‘Neighborhood INTEGRITY (Medicare-Medicaid Plan)' option.

Please note that emergency care, urgent care and dialysis, in or out of network, do not require a prior authorization.

What is the process for obtaining Prior Authorization?

The Prior Authorization information for medical services and drugs that are administered under the  medical  benefit can be found by clicking the link below:

For standard requests a decision is made within 14 calendar days from the date the request was received. A written notice of the decision will be sent to the member and provider.

For expedited requests a decision is made within 72 hours from the date the request was received. Neighborhood will inform the member and provider of the decision. Neighborhood utilizes Clinical Medical Policies and InterQual for medical necessity criteria which are available upon request. The Clinical Medical Policies are available on the website at www.nhpri.org/Provider/ClinicalResources

Prior authorization is not a guarantee of payment. All providers are advised to check eligibility before rendering services.

eviCore Radiology Authorizations

Neighborhood has partnered with eviCore healthcare for prior authorization of outpatient elective CT, MR, PET, CT Cardiac, MRI Cardiac, PET Cardiac, Nuclear Cardiology, and 3D Rendering Procedures.

You can access their prior authorization forms and clinical criteria at:  
https://www.evicore.com/pages/providerlogin.aspx

Please note: eviCore will accept prior authorizations from either the ordering or rendering provider prior to the service being rendered.

Have questions?

Please call us at 1-844-812-6896 (TTY 711), 8 am to 8 pm, Monday – Friday; 8 am to 12 pm on Saturday. On Saturday afternoons, Sundays and holidays, you may be asked to leave a message. Your call will be returned within the next business day. The call is free.

Neighborhood Health Plan of Rhode Island is a health plan that contracts with both Medicare and Rhode Island Medicaid to provide the benefits of both programs to enrollees.

ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call Member Services at 1-844-812-6896 (TTY 711), 8 am to 8 pm, Monday – Friday; 8 am to 12 pm on Saturday. On Saturday afternoons, Sundays and holidays, you may be asked to leave a message. Your call will be returned within the next business day. The call is free.

ATENCIÓN: Si usted habla Español, servicios de asistencia con el idioma, de forma gratuita, están disponibles para usted. Llame a Servicios a los Miembros al 1-844-812-6896 (TTY 711), de 8 am a 8 pm, de lunes a viernes, de 8 am a 12 pm los Sábados. En las tardes de los Sábados, domingos y feriados, se le pedirá que deje un mensaje. Su llamada será devuelta dentro del siguiente día hábil. La llamada es gratuita.

ATENÇÃO: Se você fala Português, o idioma, os serviços de assistência gratuita, estão disponíveis para você. Os serviços de chamada em 1-844-812-6896 TTY (711), 8 am a 8 pm, de segunda a sexta-feira; 8 am a 12 pm no sábado. Nas tardes de sábado, domingos e feriados, você pode ser convidado a deixar uma mensagem. A sua chamada será devolvido no próximo dia útil. A ligação é gratuita.

Our plan can also give you materials in Spanish and Portuguese and in formats such as large print, braille, or audio. Call Neighborhood INTEGRITY Member Services to make a standing request to receive your materials now and in the future, in your requested language or alternate format. Call Neighborhood INTEGRITY Member Services to make a standing request to receive your materials now and in the future, in your requested language or alternate format.

Last Updated October 14, 2018 10:04 am

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