CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Medical Necessity

Defines BCBSRI's criteria and administrative processes for determining medical necessity for covered services across Medicare Advantage and Commercial products; applies to providers submitting claims to Blue Cross & Blue Shield of Rhode Island.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyMedical Necessity

Policy CodePolicy N/A

Change TypeNo material change

Effective DateMay 9, 2017

Next Review DateN/A

Key ActionProvide required clinical documentation when requested to support determinations of medical necessity.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

NonePrior authorization requirements (policy)

Medical necessity criteriaDefined for Medicare Advantage and Commercial products

Related policyOut of Network Services

Provider updatesPublished list (most recent Mar 2023)

Coverage and Medical Necessity Criteria

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Medical necessity and coverage

Medicare Advantage medical necessity: For Medicare Advantage: service is proper and needed for the diagnosis or treatment; provided for diagnosis, direct care, and treatment; meets local standards of good medical practice; and is not primarily for the convenience of the member or their doctor.
Supporting evidence for Medicare Advantage: The healthcare services are supported by peer-reviewed medical literature/guidelines from nationally recognized organizations, meet professional standards of safety and effectiveness generally recognized in the United States, and are supported by the opinion of health professionals in the recognized specialty or any other relevant information.
Commercial medical necessity: For Commercial products: service is appropriate and effective for diagnosis, treatment, or care; appropriate with regard to generally accepted standards of medical practice or scientific evidence; not primarily for the convenience of the member, family, or provider; and is the most appropriate in terms of type, amount, frequency, setting, duration, supplies or level of service with no less expensive professionally acceptable alternative available.

Administrative and review requirements: BCBSRI may complete preauthorization or retrospective review as defined in specific medical policies. Medical records or clinical information may be requested; when requested, all specific information needed to make the medical necessity determination must be included.

Services that do not meet the medical necessity criteria or that are not a covered benefit per the member's contract are considered not medically necessary and may be denied or not reimbursed. BCBSRI may request medical records or clinical information to determine medical necessity; failure to provide required documentation can affect payment.

Provider Requirements, Authorization, and Documentation

Prior Authorization

Prior authorization note

No general prior authorization is specified for services covered under this policy. However, Blue Cross Blue Shield of Rhode Island (BCBSRI) reserves the right to require preauthorization or complete retrospective review under specific medical policies.

BCBSRI may require preauthorization as defined in specific medical policies.

Denial Risk

Denial triggers

Services that do not meet the policy's medical necessity criteria or that are not a covered benefit under the member's contract may be denied.

Denial may occur when services are not medically necessary per the policy definition.
Denial may occur when services are excluded by the member's Subscriber Agreement or are out-of-network/non-covered benefits.
BCBSRI may perform retrospective review and deny payment if documentation does not support medical necessity.

Documentation Required

Clinical documentation requirement

When BCBSRI requests medical records or clinical information to determine medical necessity, include all specific information needed to support the request.

Relevant clinical history, diagnosis, and treatment rationale.
Pertinent diagnostic test results and dates.
Documentation of prior conservative therapies and response when applicable.
Copies of operative reports, progress notes, and consultation notes as requested.

Policy Background

This administrative policy defines how Blue Cross & Blue Shield of Rhode Island determines medically necessary services for diagnosis, treatment, and care. For Medicare Advantage members, medically necessary services are those that are proper and needed for diagnosis or treatment, provided for direct care, meet local standards of good medical practice, are not primarily for convenience, and are supported by peer‑reviewed literature, safety/effectiveness standards, and professional opinion. For Commercial products, medically necessary services are those that are appropriate and effective for diagnosis or treatment, consistent with generally accepted medical practice and scientific evidence, not primarily for convenience, and are the most appropriate in terms of type, amount, frequency, setting, duration, supplies, or level of service with no less expensive professionally acceptable alternative.

Key Definitions

Medically necessary (Medicare Advantage)

DefinitionServices that are proper and needed for the diagnosis or treatment of the member's medical condition; provided for diagnosis, direct care, and treatment; meet local standards of good medical practice; and are not primarily for the convenience of the member or provider.

Evidence standardsSupported by peer‑reviewed medical literature, nationally recognized guidelines, and scientific data demonstrating efficacy or clinical validity.

Safety and professional opinionMeets professional standards of safety and effectiveness recognized in the U.S., and may be supported by the opinion of health professionals in the relevant specialty.

Actionable thresholdServices must meet CMS criteria for medical necessity (proper/needed, direct care/treatment, local good medical practice, not mainly for convenience).

Medically necessary (Commercial)

DefinitionHealthcare services that are appropriate and effective for diagnosis, treatment, or care of the member's condition upon BCBSRI review.

StandardsConsistent with generally accepted standards of medical practice or scientific evidence within the medical community.

AppropriatenessNot primarily for convenience of the member, family, or provider, and the most appropriate in type, amount, frequency, setting, duration, supplies or level of service.

Actionable thresholdCovered services must be the most appropriate option with no less expensive professionally acceptable alternative available.