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 Form can be found by clicking the link below:
We recommend that providers submit prior authorizations via fax for efficiency. Beginning August 1, 2016 providers may also submit prior authorizations through the web portal.
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 verbally. We will also mail a written notice of the decision. Neighborhood utilizes Clinical Medical Policies and MCAP 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, MR Cardiac, PET Cardiac, Nuclear Cardiology, and 3D Rendering Procedures.
You can access their prior authorization forms and clinical criteria at: http://www.medsolutions.com/documents/index.html
Please note: eviCore will accept prior authorizations from either the ordering or rendering provider prior to the service being rendered.