DraftBlue Cross Blue Shield - Rhode IslandPolicy N/A

Prior Authorization of Services, Treatments or Procedures, Effective 9/1/2026

Defines BCBSRI prior authorization requirements, processes, exemptions for select providers/specialties, applicable tools (online prior authorization tool or fax), and references to code grid and related medical policies. Applies to Medicare Advantage and Commercial products with product-specific rules.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyPrior Authorization of Services, Treatments or Procedures, Effective 9/1/2026

Policy CodePolicy N/A

Change TypeExemption updates for select providers

Effective DateSep 1, 2026

Next Review DateN/A

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.

SourceLink

POLICY UPDATE CHANGES

Effective 10/01/2025, Fully-Funded Commercial Products: prior authorization may not be needed when the requesting physician is a BCBSRI Contracted Primary Care Provider (list of specialties provided).

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

MultipleRelated policies listed

401-272-8885Fax for non-participating providers

09/01/2026

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Policy summary and applicability

This policy documents the BCBSRI prior authorization request process for certain medical procedures and specifies which products and provider types require prior authorization. Participating providers must submit requests using the BCBSRI online prior authorization tool; non-participating providers should fax requests to Utilization Management at 401-272-8885.

Medical necessity is determined using InterQual criteria found in the online authorization tool, or CMS NCD/LCD criteria for Medicare Advantage members when applicable. For policies listed in the Related Policies section, BCBSRI medical criteria (also in the online tool) are used.

Prior authorization is required for Medicare Advantage Plans and recommended for Commercial Products. Effective 10/01/2025, for Fully-Funded Commercial Products only, prior authorization requests may not be needed when the requesting physician is a BCBSRI Contracted Primary Care Provider (eligible specialties listed below). Effective 05/15/2025, certain services may also be exempt when requested by a BCBSRI Contracted Primary Care Provider; see the attached code grid for applicable services and covered codes when criteria are met.

The exemption for Fully-Funded Commercial Products (effective 10/01/2025) includes these specialties credentialed as primary care providers: Internal Medicine, Pediatric Medicine, Family Practice, Obstetrics and Gynecology, Doctor of Osteopathic Medicine, NP, PA. The 05/15/2025 exemption lists: Internal Medicine, Pediatric Medicine, Family Practice, NP, PA.

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

See the attached code grid for the specific procedure and billing codes that are covered when applicable medical criteria are met, and refer to the Related Policies section for procedures governed by BCBSRI criteria.

Prior Authorization - Key Dates & Scope

Effective date09/01/2026

Last review05/06/2025

Scope summaryDefines BCBSRI prior authorization requirements, processes, exemptions for select providers/specialties, applicable tools (online prior authorization tool or fax), and references to code grid and related medical policies. Applies to Medicare Advantage and Commercial products with product-specific rules.

PayerBlue Cross Blue Shield - Rhode Island

StatusDRAFT

Medical necessity and authorization rules

General Medical Necessity Determination

Medical procedures are considered medically necessary when the following conditions are met:

ALL of the following

Medical criteria: Applicable InterQual criteria (generally) or CMS NCD/LCD criteria for Medicare Advantage members are met as documented in the BCBSRI online prior authorization tool.
Reference BCBSRI online prior authorization tool for criteria.
Related policies: For policies specifically listed in the Related Policies section, BCBSRI medical criteria are used as found in the online authorization tool.
See Related Policies list in policy document.

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Referenced codes and code grid

Codes referenced in attached grid (covered when criteria met)mixedCovered

No codes listed

What providers must do

Prior Authorization

Use online prior authorization tool or fax for non-participating providers

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

Fax: 401-272-8885

Prior Authorization

Retrospective authorization for urgent or unknown-complexity services

If a service requiring prior authorization is performed urgently or the complexity is unknown prior to the service, obtain a retrospective authorization through the BCBSRI online prior authorization tool.

Documentation Required

Medical necessity determination via online tool criteria

Recent policy changes

10/01/2025AddedLatest

Effective 10/1/2025, for Fully-Funded Commercial Products only, prior authorization requests may not be needed when the requesting physician is a BCBSRI Contracted Primary Care Provider. Eligible specialties for this exemption include Internal Medicine; Pediatric Medicine; Family Practice; Obstetrics and Gynecology; Doctor of Osteopathic Medicine; NP/PCP; and PA.

05/15/2025Added

Effective 5/15/2025, prior authorization requests for certain services may not be needed when the requesting physician is a BCBSRI Contracted Primary Care Provider. See attached code grid for applicable services. Eligible specialties for this exemption include Internal Medicine; Pediatric Medicine; Family Practice; NP/PCP; and PA.

Prior Authorization Requirement by Product

Authorization requirements vary by product and provider type:

ALL of the following

Medicare Advantage and Commercial
- Medicare Advantage: Prior authorization is required for Medicare Advantage Plans.
- Commercial: Prior authorization is recommended for Commercial Products.
Fully-Funded Commercial exemption (effective 10/01/2025): Effective 10/1/2025, for Fully-Funded Commercial Products only, prior authorization requests may not be needed when the requesting physician is a BCBSRI Contracted Primary Care Provider (see specialties list).
Applies to Fully-Funded Commercial Products only.
Other Commercial and Self-Funded: Prior authorization continues to be needed for all other Commercial Products, including SelfFunded and Medicare Advantage Plans.
If service is urgent or complexity unknown
- Urgent services: If a service requiring prior authorization is performed on an urgent basis, a retrospective authorization must be obtained through the online tool.
  Obtain retrospective authorization via online tool.
- Unknown complexity: If the complexity of a procedure is unknown prior to the service, a retrospective authorization must be obtained.
  Obtain retrospective authorization via online tool.