December 2019
In response feedback from the Neighborhood provider network, Neighborhood Health Plan of Rhode Island has updated our retro authorization process to better support providers while staying in line with industry standards.
- Neighborhood requires that providers request authorization for services prior to providing services to our members. Exceptions to this policy are made only under extenuating circumstances.
- Neighborhood will accept a request for retroactive authorization if the request meets either of the following guidelines:
- The request precedes a bill for services (no claim received by Neighborhood) and is within 72 hours of the service, or
- The request precedes a bill for services (no claim received by Neighborhood), is within 14 days of service, and one of the extenuating circumstances detailed below applies.
- Extenuating Circumstances fall into three categories
- Unable to Know Situation – The provider and/or facility is unable to identify from which health plan to request an authorization. The patient was not able to tell the provider about their insurance coverage, or the provider verified different insurance coverage prior to rendering services. Provider to submit with authorization request the verification that was done.
- Not Enough Time Situation – The patient requires immediate medical services and the provider is unable to anticipate the need for a prior authorization immediately before or while performing a service.
- An enrollee is discharged from a facility and insufficient time exists for institutional or home health care services to receive approval prior to the delivery of the service.
- For additional detail refer to the Neighborhood Provider Manual