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 and Physical Medicine (Evolent), Oncology and Radiation Oncology (Evolent) 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.
- If you are searching for a pharmacy code, click here to access the Medical Pharmacy Benefit Searchable HCPCS Listing (Including J-Codes) which includes Neighborhood medical benefit drug coverage by HCPCS code, by product, and prior authorization requirements (if applicable).
Results:
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 Evolent for prior authorization of Physical Medicine (Occupational Therapy, Physical Therapy, and Speech Therapy) and outpatient elective High End Radiology (MRI, MRA, CT/CTA, PET, CCTA, Nuclear Stress, MUGA Scan, Stress Echocardiology, and Echocardiology) Procedures.
Quick Reference Guide, FAQ, Tip sheets/Checklists, Cardiology/Radiology CPT Code List (for In and Out of Network Providers), and in-scope High End Radiology CPT Codes can be here.
In-scope Physical Medicine CPT Codes can be found here.
Providers can request access to Evolent’s online portal for advanced imaging and physical medicine services by visiting Evolent’s website and completing the registration process.
Clinical Practice Guidelines/Authorization Criteria
To receive Utilization Management Criteria in writing, please contact RadMDSupport@evolent.com or call 1-800-327-0641.
Neighborhood partners with Evolent, an oncology quality management company, to simplify the administrative process for providers and to support Neighborhood patients who require Oncology or Radiation Oncology services.
Click here to open the Evolent 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 Evolent* via the Evolent provider portal or call 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.
Additional resources:
- Durable Medical Equipment (DME) Guide for Frequency, Quantity Limits, and Prior Authorization Requirements (Updated June 12, 2024)
- Integra Partners Fax: 248-844-3824
- Integra Partners Phone: (888) 729-8818