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Clinical Coverage Criteria

Here you'll find the guidelines that we at Neighborhood Health Plan use to determine the most clinically appropriate level of care for all NHP health plans.

The documents outline coverage criteria for all members of all health plans, for the conditions listed below.* All documents are formatted to make it easy to understand our criteria, including:

  • Authorization, notifications, and referrals requirements
  • Exact coverage guidelines
  • Exclusions (if they apply)
  • Definitions
  • Related policies
  • The history of that coverage criteria
  • References
  • General conditions of payments

To inquire on guidelines not listed here, please contact the Provider Service Center at 1-855-444-4647.

A B C D E F G H I J K L M N O P Q R S T U V W X Y Z

*Please note that these Clinical Criteria are not intended to certify coverage availability.

While services or technology may be determined by Neighborhood Health Plan as medically necessary, it may not be part of a Member's benefit plan. Please contact our Customer Service Center at 1-800-462-5449 for verification that a service is covered under a particular benefit plan.

The definition of the term "medical necessity" is the definition contained in the NHP Provider Manual in effect on the date of the medical service in question. The foregoing criteria may be amended or rescinded at any time by NHP and NHP shall have the exclusive right to interpret and enforce its terms.