Information for PCPs on the Rhode Island Prior Authorization Reform Act

Under the Rhode Island Prior Authorization Reform Act, which took effect on Oct. 1, 2025, prior authorization requests may not be needed for certain services for Rhode Island members of our Tufts Health RITogether and Harvard Pilgrim Health Care fully insured Commercial plans — when the requesting physician is a contracted primary care physician and the services are being provided in the normal course of primary care treatment. This pilot program waives prior authorization requirements for admissions, services, and procedures ordered by in-network primary care physicians (PCPs). The following FAQ offers details on this legislation.

Under the Rhode Island Prior Authorization Reform Act, prior authorization requests may not be needed for services, treatments, and procedures ordered by a credentialed and contracted PCP when provided in the normal course of primary care treatment.

This is a three-year pilot, running from Oct. 1, 2025 through Oct. 1, 2028.

This legislation applies to Rhode Island members enrolled in our Tufts Health RITogether and Harvard Pilgrim Health Care fully insured Commercial plans.

Yes. Providers must be contracted and credentialed as PCPs with the health plan to be eligible for the pilot’s prior authorization exemption.

No. Any prior authorization requirements for medications are still required for Rhode Island members.

No. The pilot does not change or waive member copays, coinsurance, deductibles, or other cost share obligations.

In these instances, the request would follow our standard process and be reviewed for medical necessity.

Please contact the Provider Service Center for additional information.

For Commercial products

Prior authorization requests may not be required for certain services for members enrolled in Harvard Pilgrim Health Care fully insured, Commercial Rhode Island plans when:

  • The physician is credentialed and enrolled as an in-network PCP.
  • The provider meets the definition of a PCP included in the legislation. (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.)
  • The services are ordered by a credentialed and contracted PCP within the normal course of providing primary care treatment. (Providers who do not adhere to this standard may be removed from pilot participation.)

For more information, please refer to the legislation and information on the Rhode Island Executive Office of Health and Human Services website.

No, specialists must still obtain prior authorization for services that require one, even when a PCP has referred the member for specialty care.

For Harvard Pilgrim Commercial members, submit claims as you do today, and include the ordering PCP information to ensure that the exemption is applied.

For RITogether

Prior authorization requests may not be required for certain services for members enrolled in Harvard Pilgrim Health Care fully insured, Commercial Rhode Island plans when:

  • The provider is screened and enrolled with Rhode Island Medicaid.
  • The physician is credentialed and enrolled as an in-network PCP. The provider meets the definition of a PCP included in the legislation. (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.)
  • The services are ordered by a credentialed and contracted PCP within the normal course of providing primary care treatment. The waiver applies in situations where the PCP has participated in clinical decision-making related to the request. (Providers who do not adhere to this standard may be removed from pilot participation.)
  • The provider is providing or ordering a service for a member on their PCP panel.

For more information, please refer to the legislation and information on the Rhode Island Executive Office of Health and Human Services website

Generally, while specialists must continue to obtain prior authorization for services that require one, even when a PCP has referred the member for specialty care, there are certain service codes identified by RI EOHHS for which a specialist may be eligible for the exemption.

Be sure to include the ordering/rendering PCP’s information on the claim; failing to include the ordering/rendering PCP will result in the claims denying for lack of prior authorization. 

If the rendering provider is a specialist who is providing a service EOHHS has designated as eligible for exemption, the ordering PCP information must be included on the claim to bypass the prior authorization requirement. The ordering PCP should only be included if the PCP participated in clinical decision-making related to the request.