What is Prior Authorization?
A prior authorization means that you must get approval from Neighborhood before getting a specific service, drug, or see an out-of-network provider. The review process and coverage decision is based on medical necessity. We review all of the information that is given to us, including medical records. If we need more information, we may contact your provider.
What services require Prior Authorization?
To check if a service requires Prior Authorization, call Neighborhood Member Services at 1-844-812-6896 (TTY 711), 8 a.m. to 8 p.m., Monday – Friday; 8 a.m. to 12 p.m. on Saturday. You may also find out if a service is covered by checking the Member Handbook (Evidence of Coverage).Please note that emergency care, urgent care, family planning, and dialysis, in or out of network, do not need a prior authorization.
What is the process for obtaining Prior Authorization?
Neighborhood Health Plan of Rhode Island (Neighborhood) uses guidance from the Centers for Medicare and Medicaid Services (CMS) for coverage decisions, including medical necessity. Coverage decisions are based on applicable payment policies, National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs), Local Coverage Articles (LCAs), and other available CMS published guidance. In the absence of an applicable, or incomplete, NCD, LCD, or other CMS published guidance, Neighborhood will apply coverage guidance from the Rhode Island Executive Office of Health & Human Services (EOHHS), or other peer-reviewed scientific evidence such as InterQual® and/or internal Clinical Medical Policies.
For standard requests, a decision is made within 14 calendar days from the date the request was received. A written notice of our decision is then mailed to you and your provider.
For expedited requests, a decision is made within 72 hours from the date the prior authorization request was received. Neighborhood will let you and your provider know about our decision.
Click HERE to find out more about the Neighborhood Prior Authorization process. To submit a prior authorization request, please click HERE to fill out an Online Prior Authorization Form.
Click HERE to find out more about if a medication administered at your provider’s office requires authorization.
You may also start a Prior Authorization request by calling Member Services at 1-844-812-6896 (TTY 711) 8 a.m. to 8 p.m., Monday – Friday; 8 a.m. to 12 p.m. on Saturday.
Keep in mind, a prior authorization request does not guarantee payment for your services. All Neighborhood providers are told to always check a member’s eligibility before they provide services.
Questions?
Please call us at 1-844-812-6896 (TTY 711), 8 a.m. to 8 p.m., Monday – Friday, 8 a.m. to 12 p.m. on Saturday. On Saturday afternoons Sundays, and holidays, you may be asked to leave a message. Your call will be returned within the next business day. The call is free.
Neighborhood INTEGRITY (Medicare-Medicaid Plan) is a health plan that contracts with both Medicare and Rhode Island Medicaid to provide the benefits of both programs to enrollees.
Tenemos servicios de intérprete sin costo alguno para responder cualquier pregunta que pueda tener sobre nuestro plan de salud o medicamentos. Para hablar con un intérprete, por favor llame al 1-844-812-6896 (TTY 711). Alguien que hable español le podrá ayudar. Este es un servicio gratuito.
Dispomos de serviços de interpretação gratuitos para responder a qualquer questão que tenha acerca do nosso plano de saúde ou de medicação. Para obter um intérprete, contacte-nos através do número 1-844-812-6896 (TTY 711). Irá encontrar alguém que fale o idioma Português para o ajudar. Este serviço é gratuito.
យើងមានសេវាអ្នកបកប្រែផ្ទាល់មាត់ដើម្បីឆ្លើយរាល់សំណួរដែលអ្នកអាចមានអំពីគម្រោងសុខភាព និងថ្នាំរបស់យើងខ្ញុំ។ ដើម្បីទទួលបានអ្នកបកប្រែផ្ទាល់មាត់ គ្រាន់តែហៅទូរសព្ទមកយើងខ្ញុំតាមរយៈលេខ 1-844-812-6896 (TTY 711)។ អ្នកដែលនិយាយខ្មែរជួយអ្នកបាន។ នេះជាសេវាកម្មឥតគិតថ្លៃ។
Our plan can also give you materials in Spanish, Portuguese, and Khmer in formats such as large print, braille, or audio. Call Neighborhood INTEGRITY Member Services to make a standing request to receive your materials now and in the future, in your requested language or alternate format. Call Neighborhood INTEGRITY Member Services to make a standing request to receive your materials now and in the future, in your requested language or alternate format.
Last updated: November 15, 2024 @ 11:44 am
H9576_WebPA25_Approved 10/23/24