What is Prior Authorization?
A prior authorization means that you must get approval from Neighborhood Health Plan of Rhode Island (Neighborhood) before getting a specific service, drug, or seeing an out-of-network provider. The review process and coverage decision is based on medical necessity and benefit coverage. We review all of the information that is given to us, including medical records. If we need more information, we may contact your provider.
What services require Prior Authorization?
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.
How are Prior Authorization decisions made?
Neighborhood uses guidance from the Centers for Medicare and Medicaid Services (CMS) for coverage decisions, including medical necessity.
For covered services, clinical 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 peer-reviewed scientific evidence such as InterQual® and/or internal Clinical Medical Policies.
What is the process for getting a Prior Authorization?
Talk to your provider or a member of your provider’s office if you need to get prior authorization for a health care service or drug. They can work with Neighborhood on your behalf to submit a prior authorization request.
- For standard requests, Neighborhood will make a decision within 7 calendar days from the date the request was received. A written notice of our decision is then sent to you and your provider.
- For expedited requests, a decision is made within 72 hours from the date the prior authorization request was received. Neighborhood will let you and your provider know about our decision.
You 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 for your services. 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.
Questions?
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.
H2126_0725MMWBLPPrrAthrztn_M Approved 10/14/2025
Last updated: October 14, 2025 at 1:00 p.m.