Prior Authorization Reference Guide – Exchange

  • The purpose of these guides (below, by line of business) is to inform you of services that require prior authorization.
  • If you do not find a specific service listed on these guides, 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 Coverage Summaries or call Neighborhood Provider Services at 1-800-963-1001.
  • All Acute and Post-Acute admissions require authorization.
  • Neighborhood Health Plan of RI utilizes the following criteria to make medical review decisions:
    • InterQual
    • Clinical Medical Policies
  • Access Prior Authorization Forms here.  Forms can be completed online or submitted to the 24/7 fax line at 401-459-6023.If you have any questions about the authorization process, please call Utilization Management at 401-459-6060.
  • For the following areas: Radiology, Oncology and Durable Medical Equipment please see our partnered vendor information below regarding authorization requirements

 

Radiology Authorization Information

Radiology Authorizations

Neighborhood has partnered with eviCore Healthcare for prior authorization of outpatient elective CT, MR, PET, CT Cardiac, MR Cardiac, PET Cardiac, Nuclear Cardiology and 3D Rendering Procedures.  Out of Network Providers: Please see NHPRI auth guide for additional radiology codes that may require auth

Please note: Neighborhood and eviCore will accept authorizations from either the ordering or rendering provider prior to the service being rendered.

Additional resources:

For more information visit eviCore.

Oncology Authorization Information

Oncology Authorizations

Neighborhood has partnered with New Century Health – Program for oncology-related drugs and/or treatment.

ICD-10, CPT and HCPC code list for Genomic and Radiation Oncology

 

Durable Medical Equipment (DME) Authorization Information

DME Authorizations

Neighborhood has partnered with Integra Partners- manages the DME vendor network and authorization process for DME delivered in the home. Please see NHPRI auth guide for DME HCPC codes rendered in POS other than 12(home). 

 

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