Utilization Management Update

December 2019

The goal of Utilization Management services at Neighborhood Health Plan of Rhode Island is to affect positive patient outcomes by addressing utilization processes in a timely manner while adhering to all regulatory guidance and established medical necessity criteria.

Prior Authorization

  • Neighborhood requires prior authorization for certain services prior to the delivery of such services as a condition of payment.
  • To maintain regulatory timeframes, prior authorization requests should be initiated as soon as services are contemplated.
  • The following information is required from the referring or treating practitioner in order to be considered a complete request:
    • Members full name
    • Member date of birth
    • Member’s NHPRI member identification number
    • Requesting provider
    • Provider, hospital clinic, or ancillary provider planned to provide the service
    • Anticipated dates of services
    • Principle diagnosis related specifically to this service
    • Principle procedure codes related specifically to this service
    • Services or level of care requested
    • Complete clinical information that supports the following:
      • medical necessity of the planned procedure,
      • level of care requested, and
      • place of service requested
    • You must also indicate if you are aware of any third party liability (e.g. other health insurance coverage, workers compensation, automobile insurance)
  • Note: An inpatient admission associated with services requiring prior authorization (i.e. surgical procedure) must also have an approved prior authorization request initiated by the treating provider (i.e. the surgeon) prior to the inpatient admission. Requests should be faxed directly to the UM department at 1-401-459-6023.

Decision Timeframes

  • Neighborhood makes decisions and communicates them as expeditiously as the enrollee’s health condition requires and within the following timeframes:
    • Standard Requests: within 14 days from receipt of request
    • Expedited Requests: within 72 hours from receipt of request
  • A timely request accompanied by all pertinent clinical information allows for timely decisions