We want to make primary care physicians who care for Rhode Island members enrolled in our Harvard Pilgrim Health Care Commercial fully insured and Tufts Health RITogether plans aware of recent Rhode Island legislation related to prior authorizations.

Under the Rhode Island Prior Authorization Reform Act of 2025, prior authorization requests may not be needed for certain services for Rhode Island members of these plans when the services are ordered by in-network PCPs and are provided in the normal course of primary care treatment.

This three-year pilot program is effective from Oct. 1, 2025 through Oct. 1, 2028.

The legislation outlines requirements in order for a PCP to qualify for the exemption, including, but not limited to, that the PCP must be credentialed and enrolled in the network, that the PCP must be enrolled with Rhode Island Medicaid if the member is a Medicaid member, and that the PCP meets the definition of a PCP outlined in the legislation. 

For Commercial members, specialists are not eligible for this exemption; for RITogether members, Rhode Island Executive Office of Health and Human Services (EOHHS) has noted some specific services and codes for which specialists may be eligible for exemption. 

Eligible provider types when credentialed as PCPs include: internal medicine, pediatric medicine, family practice, obstetrics and gynecology, Doctor of Osteopathic medicine, nurse practitioner/PCP, and physician assistant.

It’s also important to note that only services provided in the normal course of primary care treatment are eligible for this exception.

If a PCP opts to submit a prior authorization request for which an exemption applies, the request will follow our standard process and be reviewed for medical necessity.

To assist PCPs in understanding this pilot program, we have developed an FAQ on our provider website. In addition, we encourage PCPs to refer to the Rhode Island Executive Office of Health and Human Services website for more information.