This webpage is designed to inform network and out-of-network providers on Neighborhood’s prior authorization processes. In addition, providers can scroll down on this page for authorization processes with Neighborhood business partners for Radiology (eviCore), Oncology (New Century Health) and Durable Medical Equipment (Integra Partners).
Neighborhood Prior Authorization Search Tool – New!
The new Neighborhood Prior Authorization Search Tool (PA Search Tool) replaces the former Prior Authorization Reference Guides to inform our providers what Neighborhood services require prior authorization. With the new PA Search Tool, providers simply enter the procedure/service code in question and select the member’s line of business to determine if prior authorization from Neighborhood is required.
If prior authorization (PA) from Neighborhood is necessary, the PA Search Tool will display the required process/form. Please note, all acute and post-acute inpatient admissions require authorization.
- If you do not find a specific service in your search, it may be that the service is a non-covered benefit. If you need information related to covered services, please refer to our Billing Guidelines and Payment Polices or call Neighborhood Provider Services at 1-800-963-1001.
All Prior Authorization Forms are available on the Neighborhood website. Neighborhood prefers our providers use the electronic forms (eForms) for PA requests to ensure we receive complete, accurate, and legible information. Paper PA request forms can be submitted to the 24/7 fax line at 401-459-6023.
To determine medical necessity, Neighborhood utilizes the InterQual® criteria-based medical decision support system, in addition to Neighborhood’s Clinical Medical Policies. More information on the PA process can be found in the Neighborhood Provider Manual If you have any questions or experience issues with your search or request, please call Utilization Management at 401-459-6060.
Neighborhood partners with eviCore Healthcare for prior authorization of outpatient elective CT, MR, PET, CT Cardiac, MR Cardiac, PET Cardiac, Nuclear Cardiology and 3D Rendering Procedures.
eviCore’s provider portal now features a new and improved process for cases denied due to missing evidence of conservative treatment
- New! If a single CPT-code case was denied for lack of conservative treatment, you can validate that treatment has occurred. Note: The start and completion dates must be at least 6 weeks apart or the case will automatically move to an appeals nurse for review.
- New! If the 6-week requirement is met, you’ll receive a confirmation message and be asked to upload clinical documentation. If the upload is successful, you’ll receive confirmation. Then when you click “Submit” the case will automatically be approved. You can refresh the case status to view the approval authorization number and information.
In-network providers: Please consult the eviCore Cardiology and Radiology CPT Code List to verify authorization requirements.
Out-of-network providers: Please first consult the eviCore Cardiology and Radiology CPT Code List and then check the Neighborhood Prior Authorization Search Tool above for additional radiology codes that may require authorization.
Neighborhood partners with New Century Health (NCH), an oncology quality management company, to simplify the administrative process for providers and to support Neighborhood patients with oncology-related drugs and/or treatment.
Click here to open the NCH guide of diagnosis codes and procedures codes for genomic or radiation oncology. If both ICD-10 and accompanying CPT/HCPC is listed, your request for authorization must be sent to NCH* via the NCH provider portal or calling 1-888-999-7713 (Option 1 for Medical Oncology and Genomic/Genetic Testing; Option 2 for Radiation Oncology).
*If you are an out-of-network provider please send the request directly to Neighborhood, even if the codes are on both lists.
Neighborhood’s Durable Medical Equipment (DME) provider network and authorization process for DME delivered in the home is managed by Integra Partners. For non-DME providers, please review FQLI linked below if you do not find your code please go to the authorization search tool and enter your code to see if there are additional authorization requirements. If your code requires prior authorization, please submit your request directly to Neighborhood. If you have any questions regarding DME authorizations, please visit the Integra Partners website for more information.
- Durable Medical Equipment (DME) Guide for Frequency, Quantity Limits, and Prior Authorization Requirements (Updated November 6, 2023)
- Integra Partners Fax: 248-844-3824
- Integra Partners Phone: (888) 729-8818