CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Out-of-Network Services Requests

Defines when services from non-contracted/out-of-network providers may be considered at the member's in-network benefit level for Commercial products and describes the review/notification process for such 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 services request form and supporting information to Utilization Management via fax (401) 272-8885.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

CommercialPolicy applies to

48 hrsBehavioral health notification timeframe

UM faxSubmission channel

Not applicableCoding

Coverage Criteria for Out-of-Network Requests

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Commercial Products - in-network consideration: Services are determined to be urgent or emergent.

Commercial Products - in-network consideration: There is not a 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.

Commercial Products - in-network consideration: A newly enrolled member who is at 24 weeks of pregnancy or greater and the obstetrical provider is a non-contracted/out-of-network provider.

Commercial Products - in-network consideration: A newly enrolled member who is in an active course of treatment with a non-contracted provider.

Active treatment: 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, direct treatment, prescribing or modifying treatment.

Tiered network - lower-tier benefit consideration: For plans with tiered networks, there is not a lower-tier provider within the health plan's network that has the expertise to provide the medically necessary service within a reasonable timeframe for the member's condition.within a reasonable timeframe

Applies when Subscriber Agreement includes process for requesting higher-tier services at lower-tier benefit level.

Examples of qualifying conditions: Examples include ongoing oncology treatment (radiation or chemotherapy), post-operative or staged surgical procedures (e.g., cleft repair/palate cycle), and acute exacerbation of chronic conditions requiring ongoing treatment (e.g., acute exacerbation of chronic asthma).

Determinations for oncology may be approved through the current course of therapy.

Provider Actions and Submission Instructions

Prior Authorization

Prior Authorization Recommendation

Prior authorization is recommended for Commercial Products for services other than the behavioral health services listed in the Notification of Admission section. Providers should confirm prior authorization requirements with BCBSRI before delivering non-behavioral out-of-network services to avoid claim denials or unexpected member liability.

Applicable to Commercial Products.
Behavioral health inpatient and specified behavioral levels of care are excluded (see Behavioral Health Notification callout).

Denial Risk

Denial Triggers / In‑Network Benefit Level Criteria

Requests for out-of-network services (other than behavioral health) will not be processed at the member's in‑network benefit level unless one of the following criteria is met: the services are urgent or emergent; there is no in‑network provider with the necessary expertise/availability; the member is newly enrolled and ≥24 weeks pregnant with a non‑contracted obstetrical provider; or the member is newly enrolled and in an active course of treatment with a non‑contracted provider (see policy for examples such as ongoing oncology treatment).

Active course of treatment: regular visits, direct treatment, medication management, or treatment modification to prevent recurrence or worsening.
Tiered networks: higher‑tier provider services may be covered at lower‑tier benefit if no lower‑tier provider with required expertise is available within a reasonable timeframe.

Documentation Required

Submission Instructions for Out‑of‑Network Requests

Submit the out‑of‑network services request form and any instructed supporting information to BCBSRI Utilization Management for Commercial Products. Fax the completed form and supporting documents to (401) 272‑8885 as instructed on the form. Contact Utilization Management for questions about submission.

Use the out‑of‑network services request form for non‑behavioral requests.
Fax: (401) 272‑8885.

Note

Behavioral Health Notification of Admission

For behavioral health inpatient admissions and specified behavioral levels of care listed below, notification to BCBSRI is required rather than prior authorization. Notify BCBSRI within 48 hours of admission and within 48 hours after discharge to ensure correct claims processing.

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.
For more information: BCBSRI Behavioral Health Utilization Management at 1‑800‑274‑2958.

Note

Additional Provider Actions (See Full Policy)

(Placeholder) No additional provider action notes were provided in source content. Refer to the full policy document for any other provider responsibilities not captured here.

Background

For the purposes of this policy, active treatment refers to ongoing management of an acute condition in which continuity with the treating provider may prevent recurrence or worsening and could affect expected outcomes. Active treatment typically involves regular visits, direct therapeutic intervention, prescribing or adjusting medications, or staged care (for example, ongoing chemotherapy or radiation, post-operative care, or management of an acute exacerbation of a chronic condition). When a member is newly enrolled and is in an active course of treatment with a non‑contracted provider, services may be considered at the member's in‑network benefit level under the criteria outlined in this policy.

Definitions

Active treatment definition

DefinitionActive 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 with a practitioner to monitor the status of an illness or disorder, provide direct treatment, prescribe medication or other treatment, or modify treatment protocol.

Typical componentsRegular visits to monitor status, direct therapeutic interventions, prescribing or adjusting medications, and modifying treatment protocols as needed.

Clinical examplesAcute exacerbation of chronic asthma requiring ongoing treatment; ongoing oncology treatment such as chemotherapy or radiation; post-operative or staged surgical procedures (e.g., cleft repair/palate cycle).

ApplicabilityUsed to determine eligibility for treating services from a non-contracted provider to be considered at the member's in‑network benefit level when a newly enrolled member is in an active course of treatment with a non-contracted provider.

OpenPayer

Out-of-Network Services Requests

Coverage Criteria for Out-of-Network Requests

Provider Actions and Submission Instructions

Coding and Billing

Background

Definitions