CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Medical Policy Request Form — Review of New or Existing Services/Procedures/Therapies

A request form used by providers or requestors to submit new or existing health services, procedures, or therapies for Blue Cross Blue Shield of Rhode Island medical policy review. It captures requester contact, service details, codes, evidence, and operational estimates.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyMedical Policy Request Form — Review of New or Existing Services/Procedures/Therapies

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit the completed request form with service name/description, relevant CPT/HCPCS and ICD-10 codes, supporting literature, and FDA approval documentation if required.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1form covering request for new or existing services/procedures/therapies

fieldsincludes requester contact, service information, and supporting documentation prompts

fax/emailsubmission methods provided

Coverage Criteria

Review initiation criteria

Form submission is required to initiate review; coverage decisions are made after evaluation of the submitted information.

Submission requirements: Submit completed form with requester contact information AND name/description of the service or procedure AND applicable CPT and/or HCPCS codes AND applicable ICD-10 codes AND a complete description of the service or procedure AND authoritative evidence of safety and efficacy (attach published articles) AND FDA approval documentation when requiredall

The form also requests whether the service/procedure is new technology and asks for estimates of volume/charges and whether the service replaces or complements existing services.

The form itself does not list explicit coverage exclusions. Any exclusions applicable to a requested service or procedure are determined during the medical policy review process after submission of the form and supporting materials. Providers should expect that determinations about coverage scope or exclusion will be made based on the evidence and information provided with the request.

The form does not define specific not medically necessary conditions. Medical necessity determinations are made after review of the submitted clinical evidence, service description, and any applicable regulatory documentation provided with the request.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyMedical Policy Request Form — Review of New or Existing Services/Procedures/Therapies

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit the completed request form with service name/description, relevant CPT/HCPCS and ICD-10 codes, supporting literature, and FDA approval documentation if required.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Provider Actions & Submission Requirements

Prior Authorization

Prior Authorization / Pre‑Review Required

Prior review submission required for new or novel services/procedures. Providers must submit the named service/procedure, associated CPT/HCPCS and ICD-10 codes, a complete description of the service or procedure, the type/specialty of provider who will render it, and an estimate of expected volume and charges.

Named service/procedure
CPT and/or HCPCS codes
ICD-10 codes
Complete description of the service or procedure
Type/specialty of provider rendering the service/procedure
Estimated volume (per month or year) and expected charges

Documentation Required

Provider Submission Requirements

Action required: submit authoritative evidence of safety and efficacy (peer‑reviewed literature, clinical guidelines, technology assessments). If FDA approval is applicable, include documentation supporting approval. Indicate whether the service/procedure is new technology and whether it replaces or complements existing services.

Attach supporting literature (published articles, clinical trials, guidelines)
If FDA approval is required, include approval documentation
State whether the service/procedure is new technology (Yes/No)
If replacing/complementing existing services, provide details

Documentation Required

Required Materials — Complete Submission Checklist

Required submission materials: a completed service/procedure information form with all fields populated (see checklist), contact name if previously discussed with BCBSRI, and electronic or fax delivery as instructed below. Incomplete submissions may delay review or result in denial.

Completed service/procedure information form including contact name if applicable
All supporting documentation and literature cited
Estimates of expected volume and charges
Delivery via fax or email (see submission instructions)

Denial Risk

Insufficient Documentation — Risk of Delay or Denial

Insufficient documentation will delay processing or may lead to denial. Common missing items include incomplete code lists (CPT/HCPCS/ICD-10), missing clinical evidence, absence of FDA approval documentation when applicable, missing description of how the service fits into existing care, and absent volume/charge estimates.

Missing CPT/HCPCS or ICD-10 codes
Missing or inadequate supporting literature or evidence
No FDA approval documentation when required
No description of procedure or provider specialty
No estimated volume or expected charges

OpenPayer

Medical Policy Request Form — Review of New or Existing Services/Procedures/Therapies

Coverage Criteria

Requested Codes

Provider Actions & Submission Requirements

Background

Definitions

CPT and/or HCPCS	Health service code(s) (CPT and/or HCPC) — as requested on form
ICD-10	ICD-10 code(s) — as requested on form