Prior Authorization Information

This page helps providers determine whether prior authorization is required for services covered by Neighborhood.

Some services are managed through Neighborhood’s business partners or have separate authorization requirements. Before using the Prior Authorization Search Tool, please review the specialty authorization sections below.

Step 1: Review specialty authorization requirements

Before searching for a code in the Prior Authorization Search Tool, check whether the service falls under one of the categories below.

If the service falls into one of these categories, flip the card for the applicable section and follow the instructions provided there:

Flip all cards to view all details

Primary Care Authorization Policies

Prior authorization may no longer be required for eligible services ordered by a PCP for Medicaid and Commercial lines of business. This change aligns with Rhode Island Medicaid and Commercial regulatory requirements effective October 1, 2025, and has been implemented in Neighborhood’s claims processing systems effective July 15, 2026. Providers must review the following policies for full details on eligible and excluded services:

For more information click here

High-End Radiology and Physical Medicine Authorization Information

Evolent handles prior authorization for Physical Medicine and outpatient elective High-End Radiology – including OT, PT, speech therapy, MRI/MRA, CT/CTA, PET, CCTA, nuclear stress testing, MUGA, stress echocardiography, and echocardiography.

View the Physical Medicine CPT code list.

To request Utilization Management Criteria in writing, email RadMDSupport@evolent.com or call 1-800-327-0641.

Oncology Authorization Information

Evolent handles prior authorization for certain oncology, radiation oncology, and genomic services.

Check the diagnosis and procedure code guide; submit if both ICD-10 and CPT/HCPCS codes are listed.

Submit through the Evolent portal or call 1-888-999-7713 and choose one of the options: Option 1 for Medical Oncology/Genomic Testing; Option 2 for Radiation Oncology.

Interventional Cardiology and Musculoskeletal Surgery Programs

Effective January 1, 2026, Evolent manages prior authorization for non-emergent Interventional Cardiology and Musculoskeletal Surgery—Joint and Spine.

Applies to Neighborhood Medicaid and Medicare lines of businesses.

In-scope Services CPT Code List

Scope of Services Documentation

Use Evolent’s resource page for CPT lists, scope-of-services details, the Program FAQ, and clinical guidelines.

Durable Medical Equipment Authorization Information

Integra Partners manages Neighborhood’s home-delivered DME network and authorization process.

Review the DME frequency and quantity limits (FQLI) grid; use the authorization search tool if a code is not listed.

If code requires prior authorization and is not on the FQLI, please submit the request directly to Neighborhood

Resources/contact: Integra Partners website, 1-888-729-8818, fax 248-844-3824.

Behavioral Health Services — Out-of-Network Authorization Requirements

For dates of service on or after September 1, 2025, Neighborhood manages behavioral health services for all lines of business.

Out-of-network behavioral health providers must obtain authorization before services.

See the Behavioral Health Prior Authorization Grid, effective June 1, 2026, for requirements.

Step 2: Use the Prior Authorization Search Tool

The Prior Authorization Search Tool helps providers determine whether prior authorization from Neighborhood is required.

To use the tool:

Enter the procedure or service code.
Select the member’s line of business.
Review the results.

If prior authorization is required, the tool will display the required process or form.

If a code is not found

If a code does not appear in your search, it may mean the code is:

A non-covered benefit;
Invalid or no longer active;
An authorization-required code through one of Neighborhood’s vendors (see specialty authorization requirements above); or
Not currently included in the Prior Authorization Search Tool.

Please review Neighborhood’s Billing Guidelines and Payment Policies for covered service information.

Next Steps

Check whether the code you are submitting is a valid code.
Confirm if code is submitted through one of Neighborhood’s vendors (see above).
Please review Neighborhood’s Billing Guidelines and Payment Policies for official covered services information.

Submitting a prior authorization request

Prior Authorization forms are available on Neighborhood’s website. Neighborhood prefers providers use electronic forms whenever possible to help ensure requests are complete, accurate and legible. Paper prior authorization request forms may be faxed to 401-459-6023.

REMINDER: An authorization is not a guarantee of payment

Neighborhood uses the InterQual® criteria-based medical decision support system, in addition to Neighborhood’s Clinical Medical Policies, when reviewing prior authorization requests. More information about the prior authorization process is available in the Neighborhood Provider Manual.

CMS Interoperability Prior Authorization Metrics Report 2025 – Medicaid

NHPRI_CMS_Prior_Authorization_Metrics_Report_2025