CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Medical Coverage Policy Medical Necessity

Defines the insurer's definition and criteria for determining medical necessity for Medicare Advantage and commercial products, and describes prior authorization and documentation practices; applies broadly across BCBSRI medical policies and benefits, not a procedure- or drug-specific coverage policy.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyMedical Coverage Policy Medical Necessity

Policy CodePolicy N/A

Change TypeClarified (administrative review)

Effective DateSep 5, 2017

Next Review Date

Key ActionWhen requested, submit all medical records and clinical information needed to determine medical necessity; verify member benefits and eligibility prior to billing.

SourceLink

POLICY UPDATE CHANGES

Policy last reviewed 01|08|2025; published in Provider Update March 2025.

GeneralPolicy type

Medicare & CommercialCovered Populations

NoneCoding specificity

Policy summary

This administrative policy defines BCBSRI's medical necessity principles and the criteria used to determine whether services or supplies are medically necessary. It aligns with Centers for Medicare and Medicaid Services (CMS) definitions for Medicare Advantage and sets parallel criteria for Commercial products to determine appropriateness, effectiveness, and the most appropriate level and setting of care.

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Medical necessity criteria

Medicare Advantage medical necessity criteria

Medically necessary services or supplies per CMS are covered when ALL of the following are met:

Proper and needed: Are proper and needed for the diagnosis or treatment of the member's medical condition
Standards of practice: Meet the standards of medical practice in the local area and are not mainly for the convenience of the member or their doctor
Diagnosis, direct care, treatment: Are provided for the diagnosis, direct care, and treatment of the member's medical condition
Evidence support: Care is supported by peer-reviewed medical literature or guidelines from nationally recognized organizations or other relevant information demonstrating efficacy or clinical validity
Safety and effectiveness: Service meets professional standards of safety and effectiveness
Specialty opinion: Opinion of health professionals in the recognized specialty supports the service

Commercial products medical necessity criteria

Medically necessary services for commercial products are covered when ALL of the following are met:

Appropriate and effective for the diagnosis, treatment, or care of the condition, disease, ailment, or injury for which it is prescribed or performed
Generally accepted standards: Appropriate with regard to generally accepted standards of medical practice or scientific evidence
Not for convenience: Not primarily for the convenience of the member, the member's family, or the provider
Most appropriate: The most appropriate in terms of type, amount, frequency, setting, duration, supplies, or level of service which can safely be provided; no less expensive professionally acceptable alternative is available

Documentation and review

Preauthorization and retrospective review: BCBSRI reserves the right to require preauthorization or perform retrospective review as defined in specific medical policies
Supported by policy statement reserving right to complete preauthorization or retrospective review
Submission of records: When medical records or clinical information are requested, all information needed to make the medical necessity determination must be included
Providers must submit requested medical records and all information needed to determine medical necessity
Reimbursement contingent on criteria and coverage: Reimbursement is provided for medically necessary services when medical criteria and guidelines are met and the service is a covered benefit under the subscriber agreement
Reimbursement contingent on meeting medical criteria and being a covered benefit

What providers must do

Prior Authorization

Preauthorization and retrospective review

BCBSRI may require preauthorization or perform retrospective review as defined in specific medical policies; providers must submit requested medical records and all information needed to determine medical necessity.

Documentation Required

Medical records when requested

When medical records or clinical information are requested for medical necessity determination, include all information needed to make the determination to avoid denial or further review.

Billing Rule

Benefit and eligibility verification

Services must be a covered benefit under the subscriber agreement; providers should verify member-specific benefits and eligibility via the provider call center prior to billing.

Definitions

Medically necessaryServices provided for diagnosis, direct care, and treatment that are proper and needed, meet local standards of practice, are supported by evidence and professional opinion, and are not primarily for convenience; for commercial products also must be the most appropriate in type, amount, frequency, setting, duration, supplies or level of service with no less expensive acceptable alternative.

This is a non-procedure-specific administrative policy that defines medical necessity principles. Whether a service is a covered benefit is determined by the member's subscriber agreement or member certificate; benefits and eligibility may vary between groups/contracts.

OpenPayer

Medical Coverage Policy Medical Necessity

Policy summary

Medical necessity criteria

What providers must do

Definitions

Coding

Document history