CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Out-of-Network Services Requests

Defines when services provided by non-contracted/out-of-network providers may be reviewed and considered at the member's in‑network benefit level for BCBSRI Commercial Products, and describes submission/notification processes for those requests.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyOut-of-Network Services Requests

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit the Out-of-Network Request Form and any instructed information; fax non-behavioral requests to (401) 272-8885.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

CommercialApplies to

48 hrsBehavioral notification timeframe

FaxSubmission channel (non-behavioral)

SpecifiedBehavioral levels requiring notification

When Out‑of‑Network Services May Be Reviewed for In‑Network Benefit

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Commercial Products - Criteria for in-network benefit level

Covered at member's in-network benefit level when ANY one of the following criteria is met:

Urgent or emergent services: Services determined to be urgent or emergent.

No in-network provider with requisite expertise: No contracted/in-network provider within the health plan's network that has the expertise, training, access to, or the ability to provide the requested medically necessary services.

Newly enrolled member — late pregnancy: Newly enrolled member at 24 weeks of pregnancy or greater and the obstetrical provider is non-contracted/out-of-network.>= 24 weeks gestation

Active course of treatment for newly enrolled member: Newly enrolled member in an active course of treatment with a non-contracted provider. (Active treatment is defined in policy as ongoing management of an acute condition where provider continuity may prevent recurrence or worsening and typically involves regular visits, direct treatment, medication prescribing, or modification of therapy.)

Oncology ongoing treatment: Members engaged in an ongoing course of oncology treatment (radiation or chemotherapy) may be approved through the current course of therapy.

Post-operative, post-treatment, or staged surgical care: Members who are post-operative, post-treatment, or have begun a staged series of surgical procedures (e.g., cleft palate repair) to continue the current course of treatment.

Tiered network — lack of lower-tier provider: For plans with tiered networks that allow requesting lower-tier benefits for higher-tier providers: there is not a lower-tier provider within the health plan's network with the requisite expertise to provide the medically necessary services within a reasonable timeframe for the member's condition.

Submission, Notification, and Authorization Requirements

Prior Authorization

Prior Authorization Recommended

Prior authorization is recommended for Commercial Products for services other than the behavioral services listed in the behavioral notification requirements.

Note

Tiered Network Escalation

For tiered networks, requests to cover higher-tier provider services at a lower-tier benefit level require demonstration that no lower-tier provider is available who has the necessary expertise, training, access to, or ability to provide the requested medically necessary services within a reasonable timeframe for the member's condition.

Applies when the Subscriber Agreement includes a process for tier escalation
Must show lack of lower-tier provider with appropriate expertise and timely availability

Documentation Required

Submission Instructions

Covered services, other than behavioral health services, rendered by a non-contracted/out-of-network provider are processed at the member's in-network benefit level when one of the grounds for consideration is met (see 'Grounds for denial of in-network benefit level' callout). Submit the Out-of-Network Request Form and any other instructed information to Utilization Management; fax non-behavioral requests to (401) 272-8885.

Out-of-Network Request Form must be completed and any requested supporting documentation included
Fax non-behavioral requests to (401) 272-8885

Note

Behavioral Health Notification

For behavioral health inpatient, residential, partial hospitalization, crisis stabilization, and detox/withdrawal management admissions to a non-contracted/out-of-network provider, notify BCBSRI within 48 hours of admission and within 48 hours after discharge to ensure correct claims processing. A medical necessity review is not required for the purpose of considering services at the member's in-network benefit level when proper notification is provided.

Inpatient mental health and substance use disorder treatment
Inpatient withdrawal management (detoxification)
Crisis Stabilization (CSU)
Residential mental health and substance use disorder treatment
Partial hospitalization for mental health and substance use disorder treatment
Contact BCBSRI Behavioral Health Utilization Management at 1-800-274-2958 for more information

Denial Risk

Grounds for Denial of In-Network Benefit Level

Requests will not meet the member's in-network benefit level unless at least one of the following criteria is met. Providers should be aware these are common grounds for denial if not demonstrated: urgent or emergent services; absence of an in-network provider with the expertise, training, access to, or ability to provide the requested medically necessary services within the health plan's network; newly enrolled members at ≥24 weeks of pregnancy whose obstetrical provider is non-contracted; members in an active course of treatment with a non-contracted provider (examples include ongoing chemotherapy or radiation, or staged surgical procedures). For tiered networks, lack of a lower-tier provider with appropriate expertise and timely availability is required to approve coverage at the lower-tier benefit level.

Urgent or emergent services
No contracted/in-network provider within the health plan's network who has the expertise, training, access to, or ability to provide the requested medically necessary services
Newly enrolled member at 24 weeks of pregnancy or greater with a non-contracted obstetrical provider
Newly enrolled member in an active course of treatment with a non-contracted provider (defined as ongoing management of an acute condition where provider continuity is needed to prevent recurrence or worsening and to achieve anticipated outcomes; typically involves regular visits, direct treatment, medication management, or modification of treatment protocol) — examples: ongoing chemotherapy or radiation, staged surgical procedures
For tiered networks: no lower-tier provider within the network with the necessary expertise and availability within a reasonable timeframe

Key Definitions

Active course of treatment — definition

DefinitionActive course of treatment: when a member is receiving active treatment for an acute condition in which provider continuity may prevent recurrence or worsening and interfere with anticipated outcomes; typically involves regular visits to monitor status, provide direct treatment, prescribe medication, or modify treatment protocol.

Typical componentsRegular visits with a practitioner to monitor status, provide direct treatment, prescribe medication, or modify treatment protocol.

Clinical examplesAcute exacerbation of chronic asthma requiring ongoing treatment; ongoing oncology treatment such as chemotherapy or radiation; post‑operative or staged surgical care (e.g., cleft/palate repair) to continue the current course of treatment.

Policy useA newly enrolled member in an active course of treatment with a non‑contracted provider may have services considered at the member’s in‑network benefit level.

ScopeApplies to Commercial Products for requests to consider out‑of‑network services at in‑network benefit level when continuity of care is clinically necessary.

OpenPayer

Out-of-Network Services Requests

When Out‑of‑Network Services May Be Reviewed for In‑Network Benefit

Relevant Procedure and Diagnosis Codes

Submission, Notification, and Authorization Requirements

Policy Context and Definitions

Key Definitions