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 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.

 

Have Questions?

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 federal 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.

This information is available for free in other languages. Please call our 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 federal holidays, you may be asked to leave a message. Your call will be returned within the next business day>. The call is free.

Esta información está disponible de forma gratuita en otros idiomas. Por favor llame a nuestro Departamento de Servicios para Miembros al 1-844-812-6896 (TTY 711) de 8 am a 8 pm, lunes-viernes; sábados de 8 am a 12 pm. Los sábados por la tarde, domingos y días festivos federales, se le pedirá que deje un mensaje. Su llamada será devuelta dentro del siguiente día laborable. La llamada es gratuita.

Estas informações estão disponíveis gratuitamente noutros idiomas. Por favor telefone para os Serviços dos Membros em 1-844-812-6896 (TTY 711), das 8 às 20 horas, de Segunda a Sexta-feira; e das 8 às 12 (meio-dia) aos Sábados. Nos Sábados à tarde, Domingos e feriados federais, poderá ser-lhe pedido que deixe uma mensagem. A sua chamada será respondida no próximo dia útil. Esta chamada é grátis.

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.

Last Updated January 9, 2017, 3:55 pm

H9576_WebPA CMS Approved 9/13/16