Policies and Guidelines

• • Clinical Medical Policies
  • Billing Guidelines and Payment Policies
  • Durable Medical Equipment (DME) Guide for Frequency, Quantity Limits, and Prior Authorization Requirements (Updated June 12, 2024)
  • Prior Authorization Information – New Neighborhood PA Search Tool!
  • InterQual® Transparency Tool
    • InterQual® Conducting a Review
    • InterQual® Conducting a Level of Care Review
    • InterQual® Conducting a Prior Authorization Review

Change Healthcare’s Statement of Disclosure

The Clinical Content you are receiving is confidential and proprietary information and is being provided to you solely as it pertains to the information requested. Under copyright law, the Clinical Content may not be copied, distributed, or otherwise reproduced. In addition, the Clinical Content may contain advanced clinical knowledge which we recommend you discuss with your physician upon disclosure to you.

The Clinical Content reflects clinical interpretations and analyses and cannot alone either (a) resolve medical ambiguities of particular situations; or (b) provide the sole basis for definitive decisions. The Clinical Content is intended solely for use as screening guidelines with respect to medical appropriateness of healthcare services and not for final clinical or payment determinations concerning the type or level of medical care provided, or proposed to be provided, to a patient; all ultimate care decisions are strictly and solely the obligation and responsibility of your health care provider.

External Criteria Sources

• • EOHHS Durable Medical Equipment Coverage Guidance
  • EOHHS Special Medical Equipment, Home Modifications, And Minor Assistive Devices Coverage Guidance
  • EOHHS Surgical Procedures Coverage Guidance
  • Skilled Nursing Facility Coverage Guidance
  • Inpatient Acute Rehab Coverage Guidance
  • Home Health Services Coverage Guidance

Medicare Distinction

Neighborhood Health Plan of Rhode Island (Neighborhood) uses guidance from the Centers for Medicare and Medicaid Services (CMS) for coverage determinations, including medical necessity, for INTEGRITY for Medicare members. Coverage determinations 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 determinations from the Rhode Island Executive Office of Health & Human Services (EOHHS) coverage guidance, or other peer-reviewed scientific evidence, such as InterQual® and/or internal Clinical Medical Policies.

• Skilled Nursing Facility Coverage Guidance
• Inpatient Acute Rehab Coverage Guidance
• Home Health Services Coverage Guidance

Medicare Administrative Contractor (MAC)

A Medicare Administrative Contractor (MAC) is a network of private organizations contracted with CMS that carry out the administrative responsibilities of traditional Medicare (Parts A and B). The network is awarded a geographic jurisdiction to provide administrative functions for Medicare Part A and Part B beneficiaries. MACs are multi-state, regional contractors.

• Rhode Island’s current MACs are:
  • National Government Services (NGS) for Medicare Part A/B services.
  • Noridian Healthcare Solutions for durable medical equipment.
  • Rhode Island is part of Jurisdiction K for A/B services.