DraftBlue Cross Blue Shield - Rhode IslandPolicy N/A

Prior Authorization of Services, Treatments or Procedures

Defines BCBSRI prior authorization request process, applicable specialties exempted from PA for certain fully-funded commercial products and primary care providers, applicability to Medicare Advantage and Commercial Products, online prior authorization tool usage, and references an attached code grid of services requiring authorization.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyPrior Authorization of Services, Treatments or Procedures

Policy CodePolicy N/A

Change TypeExemptions added

Effective DateJul 1, 202623d

Next Review Date

Key ActionParticipating providers must submit prior authorization requests via the BCBSRI online prior authorization tool; non-participating providers must fax requests to Utilization Management at 401-272-8885.

POLICY UPDATE CHANGES

Effective 10/01/2025 exemption: Fully-Funded Commercial Products may not need prior authorization when requesting physician is a BCBSRI Contracted Primary Care Provider (listed specialties).

Effective 05/15/2025 exemption: prior authorization requests for certain services may not be needed when requesting physician is a BCBSRI Contracted Primary Care Provider.

2026-07-01Policy effective date

MultipleRelated policies listed

DRAFTDocument status

Policy overview

This policy describes the procedures for submitting prior authorization requests using Blue Cross & Blue Shield of Rhode Island's (BCBSRI) online prior authorization tool, specifies that medical necessity is determined using InterQual criteria (and CMS NCD/LCDs for Medicare Advantage members when applicable), and references an attached code grid that lists services requiring authorization.

The scope covers applicability to Medicare Advantage and Commercial Products, and notes exemptions for certain Fully-Funded Commercial Products when the requesting physician is a BCBSRI contracted primary care provider (effective 10/01/2025) as well as additional exemptions effective 05/15/2025 for specified services—see the attached code grid for applicable services and listed primary care specialties.

Key facts

Effective date2026-07-01

Last review2025-12-17

Document statusDRAFT

Scope summaryDefines BCBSRI prior authorization request process; exemptions from prior authorization for certain Fully-Funded Commercial Products when requesting physician is a BCBSRI Contracted Primary Care Provider; applicability to Medicare Advantage and Commercial Products; online prior authorization tool usage; attached code grid of services requiring authorization.

Policy numberN/A

PayerBlue Cross Blue Shield - Rhode Island

What providers must do

Prior Authorization

Use online prior authorization tool

Participating providers must submit prior authorization requests via the BCBSRI online prior authorization tool.

Non-participating providers must fax requests to Utilization Management at 401-272-8885.

Prior Authorization

Retrospective authorization required for urgent or unknown-complexity services

If a service requiring prior authorization is performed on an urgent basis, or the complexity of a procedure is unknown prior to the service, a retrospective authorization must be obtained through the BCBSRI online prior authorization tool.

Documentation Required

Use InterQual or CMS NCD/LCD criteria as applicable

Medical necessity is determined using InterQual criteria in the BCBSRI online prior authorization tool; for Medicare Advantage members, CMS NCD/LCDs are used when applicable. For the policies listed in the Related Policies section, BCBSRI medical criteria applies.

Material changes / effective-dated exemptions

10/01/2025added

Effective 10/01/2025 exemption: Fully-Funded Commercial Products may not need prior authorization when requesting physician is a BCBSRI Contracted Primary Care Provider (listed specialties).

10/01/2025note

Lists specialties including Internal Medicine, Pediatric Medicine, Family Practice, Obstetrics and Gynecology, Doctor of Osteopathic Medicine, NP/PCP, PA.

05/15/2025added

Effective 05/15/2025 exemption: prior authorization requests for certain services may not be needed when requesting physician is a BCBSRI Contracted Primary Care Provider.

05/15/2025note

See attached code grid for applicable services; specialties include Internal Medicine, Pediatric Medicine, Family Practice, NP/PCP, PA.

Procedural and contact details

Participating providers must submit prior authorization requests via the BCBSRI online prior authorization tool; non-participating providers must fax requests to Utilization Management at 401-272-8885.

The online prior authorization tool is available only to participating providers; use of the online tool is the required submission pathway for participating providers, while non-participating providers should use the fax route.

For urgent services or when procedure complexity is unknown prior to the service, a retrospective authorization must be obtained through the online tool.

Exemption specialties and effective dates

Effective 2025-05-15 exemption specialtiesInternal Medicine; Pediatric Medicine; Family Practice; NP (Nurse Practitioner)/PCP; PA (Physician Assistant)

Effective 2025-10-01 exemption specialtiesInternal Medicine; Pediatric Medicine; Family Practice; Obstetrics and Gynecology; Doctor of Osteopathic Medicine; NP (Nurse Practitioner)/PCP; PA (Physician Assistant)

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyPrior Authorization of Services, Treatments or Procedures

Policy CodePolicy N/A

Change TypeExemptions added

Effective DateJul 1, 202623d

Next Review Date

On This Page

OpenPayer

Prior Authorization of Services, Treatments or Procedures

Policy overview

Prior authorization requirements & exemptions

Codes requiring prior authorization

What providers must do

Material changes / effective-dated exemptions

Procedural and contact details