Primary Care Prior Authorization Pilot
The Rhode Island State Fiscal Year 2026 (SFY26) enacted budget requires the Executive Office of Health and Human Services (EOHHS) to conduct a three-year Primary Care Prior Authorization (PA) Pilot. The pilot eliminates prior authorization requirements for certain non-pharmaceutical health care services, treatments, and procedures ordered by a primary care provider (PCP) in the normal course of providing primary care treatment.
For purposes of the pilot, prior authorization is defined in statute as “the pre-service assessment for purposes of utilization review that a Primary Care Provider is required by Medicaid fee-for-service or managed care organization to undergo before a covered healthcare service is approved for a patient.”
EOHHS is working with Rhode Island Medicaid managed care organizations (MCOs) to finalize guidance which describes the services and circumstances subject to the pilot and provides additional information for providers and MCOs.
A request form for provider inclusion in the pilot for Medicaid Fee for Service and for consideration of additional codes to bypass a prior authorization requirement is linked below.