Prior Authorization of Services
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Defines BCBSRI's process and requirements for prior authorization of medical procedures using the online prior authorization tool and applicable exemptions for certain contracted primary care providers; applies to Medicare Advantage and Commercial products.
No material clinical or coverage changes in this revision.
Coverage and Medical Necessity
Coverage criteria overview
Coverage and medical necessity are determined per the BCBSRI online prior authorization tool and member-specific benefit documents.
Exceptions
- For policies specifically listed in the Related Policies section, BCBSRI-specific medical criteria (rather than InterQual or NCD/LCD) apply.
- For Medicare Advantage Members, when applicable, CMS National and Local Coverage Determinations (NCD/LCD) found in the online authorization tool are used to determine medical necessity.
Authorization Codes and Coding Rules
| See attached code grid/link | Codes listed in attached grid are covered when applicable medical criteria are met |
How to Request Authorization and Exemptions
How to Request Authorization via Online Tool (or fax for non-participating providers)
Submit prior authorization requests via the BCBSRI online prior authorization tool (available to participating providers). Non-participating providers should fax requests to Utilization Management at 401-272-8885. If a service that requires prior authorization is performed on an urgent basis, or if the complexity of a procedure is unknown prior to the service, obtain a retrospective authorization through the online tool.
- Participating providers: use the BCBSRI online prior authorization tool.
- Non-participating providers: fax requests to Utilization Management at 401-272-8885.
- Urgent or unknown-complexity services: obtain retrospective authorization via the online tool.
When Authorization Is Required and Applicability of PCP Exemptions
Prior authorization is required for Medicare Advantage Plans and is recommended for Commercial Products. For Fully-Funded Commercial Products effective 10/01/2025 (and previously referenced effective 05/15/2025 for certain services), prior authorization requests may not be needed when the requesting physician is a BCBSRI contracted primary care provider in specified specialties; prior authorization remains required for other Commercial Products including Self-Funded and Medicare Advantage Plans.
- Medicare Advantage Plans: prior authorization is required.
- Commercial Products: prior authorization recommended; exemptions apply only to Fully-Funded Commercial Products when requested by eligible BCBSRI contracted PCPs.
- Exemption effective dates noted: 05/15/2025 (earlier statement) and 10/01/2025 (for Fully-Funded Commercial Products).
- Retrospective authorization required if service is urgent or complexity unknown.
PCP Specialties Eligible for Prior Authorization Exemption
The PCP specialties included in the exemption are: Internal Medicine; Pediatric Medicine; Family Practice; Obstetrics and Gynecology; Doctor of Osteopathic Medicine; Nurse Practitioner/PCP; and Physician Assistant.
- Internal Medicine
- Pediatric Medicine
- Family Practice
- Obstetrics and Gynecology
- Doctor of Osteopathic Medicine
- NP (Nurse Practitioner)/PCP (Primary Care Physician or Provider)
- PA (Physician Assistant)
Medical Necessity Sources and Definitions
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