Prior Authorization

What is Prior Authorization?

A Prior Authorization is an approval from Neighborhood INTEGRITY you must get before you can get a specific service or drug or use an out-of-network provider. The review process and determination are based on medical necessity. 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 check if a service requires Prior Authorization, call Neighborhood Member Services at 1-844-812-6896 (TTY 711), 8 a.m. to 8 p.m., Monday – Friday; 8 a.m. to 12 p.m. on Saturday. You may also find out if a service or code is covered by checking the Member Handbook (Evidence of Coverage).

Please note that emergency care, urgent care, family planning, and dialysis, in or out of network, do not need a prior authorization

What is the process for obtaining Prior Authorization?

Neighborhood uses Clinical Medical Policies and InterQual for medical necessity criteria which are available upon request. The Clinical Medical Policies are available here.

For standard requests, a decision is made within 14 calendar days from the date the request was received. A written notice of our decision is then mailed 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.

Click HERE to find out more about the Neighborhood Prior Authorization process. To submit an online Prior Authorization please click here to fill out the Online Prior Authorization Form.

You may also start a Prior Authorization request by calling Member Services at 1-844-812-6896 (TTY 711) 8 a.m. to 8 p.m., Monday – Friday; 8 a.m. to 12 p.m. on Saturday.

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.

Have questions?

Please call us at 1-844-812-6896 (TTY 711), 8 a.m. to 8 p.m., Monday – Friday. 8 a.m. to 8 p.m., 8 a.m. to 12 p.m. on Saturday. On Saturday afternoons, Sundays, and 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.

Last updated: April 25, 2024 @ 11:14 am

H9576_WebPA24 Approved, 10/24/2023