Prior Authorization

Prior authorization means that you or your provider must get approval from Neighborhood before you receive certain treatments, tests, medications, medical equipment, or see an out-of-network provider.  

You must complete the prior authorization process before receiving the service or medication. To help avoid delays, ask your health care provider whether a prescription or treatment requires prior authorization so they can begin the process as soon as possible. 

NOTE: There are many terms that mean the same as “prior authorization,” including: 

• Preauthorization 

• Preapproval 

• Precertification 

• Prior approval 

They all mean the same thing. 

Prior authorization is not required for emergency care, even if out-of-network. 

Our goal is to make sure you get high-quality and evidence-based health care that is medically necessary and cost effective. Prior authorizations help Neighborhood: 

• Ensure that the care is medically necessary, appropriate, and covered by your plan. 

• Coordinate care between multiple providers and facilities.  

• Keep health care costs lower by choosing services or items that cost less when they work just as well.  

• Protect patients from overly risky procedures or drugs.  

• Improve outcomes by verifying that providers follow the most current clinical guidelines.  

To see if a service needs prior authorization, call Neighborhood Member Services at 1-844-812-6896 (TTY 711). You can also find out if a service is covered by checking your Dual CONNECT Evidence of Coverage.  Please note, services such as emergency care, urgent care, and dialysis for end-stage kidney disease – by an in- or out-of-network provider – do not need prior authorization.

Check to see if a medication administered at your provider’s office requires authorization. Please visit the Pharmacy Benefits Page for guidance on Pharmacy coverage decisions related to Part B medications and diabetic supplies received at the pharmacy.

Talk to your provider or a member of your provider’s office if you need to get prior authorization for a health care service, item, or drug. They can work with Neighborhood on your behalf to submit a prior authorization request. 

You or your authorized representative may also start a Prior Authorization request by calling Member Services at 1-844-812-6896 (TTY 711). Keep in mind, a prior authorization request does not guarantee payment, and services remain subject to your plan’s benefits, exclusions, and cost-sharing requirements. All Neighborhood providers are told to always check a member’s eligibility before they provide services.  

Learn more about the Neighborhood Prior Authorization process. To submit a prior authorization request, please call Neighborhood Member Services.

Learn more about the guidelines and criteria used to make coverage decisions.

Most requests are processed in a few business days. All requests are decided within state and federally required timeframes. Neighborhood works to make decisions as quickly as possible, but the timing may vary based on the type of request.  

Standard Requests 

• Neighborhood will decide within 7 calendar days after receiving the request. 

• For medications (Part B drugs), a decision will be made within 72 hours. 

Expedited Requests 

• Neighborhood will decide within 72 hours after receiving the request.  

• For medications (Part B drugs), a decision will be made within 24 hours.  

A written notice of the decision will be sent to you and your provider. In some cases, we may also call you to let you know the decision. 

Note: Decisions may be delayed if the request is missing information or required documents. 

Our team of clinicians review all the information your provider has shared with us against the highest quality clinical guidelines. The review process and coverage decision is based on medical necessity and benefit coverage. We review all the information that is given to us, including medical records, to determine whether the requested service is medically necessary and meets Neighborhood’s coverage guidelines. If we need more information, we may contact your provider. 

Neighborhood uses guidance from the Centers for Medicare and Medicaid Services (CMS) for coverage decisions, including medical necessity. Coverage decisions are based on National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs), Local Coverage Articles (LCAs), and other available CMS published guidance. 

In the absence of an applicable, or incomplete, NCD, LCD, or other CMS published guidance, Neighborhood will apply coverage guidance from other widely used treatment guidelines with peer-reviewed scientific evidence such as InterQual® and/or internal Clinical Medical Policies. 

After review of your request, Neighborhood may: 

• Approve your request 

• Deny your request 

• Ask for more information 

• Recommend you try an alternative that’s less costly, but equally effective, before your original request is approved 

These outcomes are based on input from clinical pharmacists and medical doctors who review the requests.  

If you are unhappy with your prior authorization response, you or your health care provider can ask for a review of the decision, called an appeal. We will send you and your provider a letter explaining your rights and how to start the process.

For more information on appeals, call Member Services at the number on your Neighborhood card or visit Neighborhood’s Grievance & Appeals webpage. 

An authorized representative can help request a prior authorization on a member’s behalf. Members can name a relative, friend, advocate, provider, or anyone else as an appointed representative. By signing this form, you authorize the representative to talk to Neighborhood, make requests, and get information about your case. You must give us a copy of the signed form. 

To legally appoint someone as your representative: 

1. Download and complete a copy of the Centers for Medicare and Medicaid Services (CMS) Authorized Representative Form   English   Spanish   Portuguese
   
2. Fax or mail the signed form to Neighborhood: 

Fax to: 1-401-459-6023
Mail to: Neighborhood Health Plan of Rhode Island
Utilization Management Department
910 Douglas Pike
Smithfield, RI 02917 

Please call us at 1-844-812-6896 (TTY 711) 8:00 a.m. to 8:00 p.m., seven days a week from October 1 through March 31. From April 1 through September 30, you can call us 8:00 a.m. to 8:00 p.m. Monday through Friday. You may leave a voicemail on Saturdays, Sundays, and federal holidays. 

Members and authorized representatives may also contact: 

• Medicare: 1-800-MEDICARE (1-800-633-4227 or TTY: 877-486-2048), 24 hours a day, 7 days a week 

• Medicare Rights Center: 1-888-HMO-9050 

• Elder Care Locator: 1-800-677-1116 

• The POINT: 1-401-462-4444 (TTY 711) 

• Legal Services (Rhode Island): 1-401-274-2652 

• Rhode Island Insurance Resource, Education, and Assistance Consumer Helpline (RIREACH): 1-855-747-3224 (1-855-RIREACH); ripin.org or email rireach@ripin.org. 

Neighborhood members can find complete information about Coverage Decisions, Appeals, and Grievances in their Dual CONNECT Evidence of Coverage found on the Member Materials page of our website.