Home Care Gap Notification Neighborhood Health Plan of Rhode Island (Neighborhood) values the quality care delivered to our members by our home healthcare partners. We know our partner agencies do all they can to fulfill a member’s care plan and deliver all ordered services and hours. There may be times, however, when your agency is unable to provide services for an existing Neighborhood member. In order for Neighborhood to adequately monitor any “gaps in homecare” services—specifically for Neighborhood INTEGRITY (MMP) members, Neighborhood is requesting this form be completed and submitted any time a Neighborhood MMP member has or will experience a gap in homecare services for more than one scheduled visit. For example, this Home Care Gap Notification Form should be used when an MMP member is authorized for 20 hours/week, but only 10 hours will be filled that week. This form does not need to be submitted if another staff is filling the hours. Notification to Neighborhood is required as soon as agency is aware that the gap is going to or has occurred.Provider InformationAgency NPI(Required) 10 DigitsAgency Name(Required) Error Field Contact Name(Required) First Last Contact Email(Required) Member InformationNeighborhood Member ID #(Required) Member DOB(Required) MM slash DD slash YYYY Member Name(Required) First Last Error Field Number of Authorized Hours(Required)Number of Hours Serviced(Required)Date Services Stopped(Required) MM slash DD slash YYYY Date Services Resumed MM slash DD slash YYYY Reason For Gap(Required)Reason For Gap *Medical AppointmentRefused ServicesNot At Home For ServicesVacationOtherOther(Required) Who Assisted/Will Be Assisting The Member During The Agency Gap? Include Name and Relationship(Required) Neighborhood Case Manager (If Known) Use The Space Below For Any Additional Notes Or CommentsCAPTCHA