CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Out-of-Network Services Requests

Defines review process and criteria for considering services from non-contracted/out-of-network providers at the member's in-network benefit level for Blue Cross Blue Shield of Rhode Island commercial products.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyOut-of-Network Services Requests

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateFeb 5, 2024

Next Review DateN/A

Key ActionSubmit out-of-network non-behavioral service requests to Utilization Management and fax supporting information to (401) 272-8885.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Commercial onlyApplicability

48 hoursBehavioral notification

RecommendedPrior auth

FaxSubmission route

Coverage Criteria for Commercial Products

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Out-of-network coverage criteria

Urgent/Emergent: Services are determined to be urgent or emergent.
No in-network provider with appropriate expertise: 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.
Newly enrolled pregnant member ≥24 weeks: A newly enrolled member who is at 24 weeks of pregnancy or greater and whose obstetrical provider is non-contracted/out-of-network.
Active course of treatment with non-contracted provider: A newly enrolled member who is in an active course of treatment with a non-contracted provider (active treatment defined as receiving treatment for an acute condition where provider continuity may prevent recurrence or worsening and interfere with anticipated outcomes; typically involves regular visits to monitor status, provide direct treatment, prescribe or modify therapy).
Examples include acute exacerbation of chronic asthma requiring ongoing treatment, ongoing oncology treatment (e.g., radiation/chemotherapy), post-operative or post-treatment care, or staged repair situations.
Tiered network higher-to-lower tier coverage: For tiered networks where the Subscriber Agreement allows requesting higher-tier provider services at the lower-tier benefit level: covered services from a higher-tier provider are covered at the lower-tier benefit level when there is not a lower-tier in-network provider with the expertise, training, access to, or ability to provide the requested medically necessary services within a reasonable timeframe for the member's condition.

Operational examples: Includes examples: acute exacerbation of chronic asthma, ongoing oncology treatment (radiation/chemotherapy), post-operative/post-treatment or staged repair situations.

Benefits and network provisions may vary between groups and contracts. Refer to the member's Subscriber Agreement or member certificate for applicable network coverage, benefit design, and any terms that supersede this policy. This policy is informational and does not guarantee payment; benefit and eligibility determinations are governed by the subscriber or employer agreement.

If services are determined to be not medically necessary or are non‑covered benefits, providers may not charge the member for those services unless the member was informed in advance and provided written agreement to accept financial responsibility, consistent with participation agreements. Always consult applicable participation agreements and member documents for specific balance‑billing and consent requirements.

Provider Actions and Submission Requirements

Prior Authorization

Prior Authorization Recommended

Prior authorization is recommended for Commercial Products for services other than the behavioral services listed below.

Note

Behavioral Health Notification — 48‑Hour Requirement

Notify BCBSRI Behavioral Health Utilization Management within 48 hours of admission and within 48 hours after discharge for the following behavioral health levels of care to ensure correct claims processing. Medical necessity review is not required when the member (or their provider) requests non-contracted/out-of-network behavioral services be considered at the member’s in‑network benefit level; instead use the notification process below.

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: 1-800-274-2958

Documentation Required

Submission Requirements for Out‑of‑Network Non‑Behavioral Services

Submit requests for out-of-network services (non-behavioral) to Utilization Management using the required form and fax number. Complete the form and include any additional information requested on the form.

Fax completed form to (401) 272-8885
Benefits may vary by group/contract — refer to the Subscriber Agreement for applicable network coverage

Denial Risk

Denial Triggers — Reasons Requests May Be Denied

Requests may be denied if none of the following criteria are met: the service is urgent/emergent; there is not an in‑network provider with the necessary expertise, training, access to or ability to provide the requested medically necessary services; the member is a newly enrolled pregnant member at ≥24 weeks with a non‑contracted obstetrical provider; or the member is newly enrolled and in an active course of treatment with a non‑contracted provider. Active treatment means ongoing care for an acute condition where provider continuity may prevent recurrence or worsening and where regular visits are typical.

Urgent or emergent services
No in‑network provider with required expertise/training/access/ability
Newly enrolled member ≥24 weeks pregnant with non‑contracted obstetrical provider
Newly enrolled member actively undergoing course of treatment with a non‑contracted provider (ongoing visits, monitoring, direct treatment, medication management)
Oncology ongoing courses of treatment (e.g., radiation, chemotherapy) and certain post‑operative or staged repair care may qualify

Definitions

Active treatment definition — inv-11

DefinitionActive treatment: member is receiving active treatment for an acute condition in which provider continuity may prevent recurrence or worsening of the condition and interfere with anticipated outcomes.

Typical elementsTreatment typically involves regular visits with a practitioner to monitor status, provide direct treatment, prescribe medication or other treatment, or modify treatment protocol.

ExamplesQualifying examples include acute exacerbation of chronic asthma requiring ongoing treatment; ongoing oncology treatment such as radiation or chemotherapy; post‑operative or post‑treatment staged repair situations.

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

Background

This document is administrative in scope and defines the coverage determination criteria and operational processes used to consider services from non‑contracted (out‑of‑network) providers at the member's in‑network benefit level for Blue Cross & Blue Shield of Rhode Island Commercial Products. It describes the conditions under which out‑of‑network services may be processed at the in‑network benefit level, submission pathways for non‑behavioral out‑of‑network requests, and the interplay with member contract terms, rather than providing clinical indications or treatment guidance.

Revision History

2025-07-02policy_reviewedLatest

Policy last reviewed on 07/02/2025 per document header.

2024-02-05effective_date

Policy effective date established as 02/05/2024.

2024-02provider_update

Provider Update published in February/October 2024 as listed in publication history.

2023-07provider_update

Provider Update published July 2023 per publication history.

2022-07provider_update

Provider Update published July/August 2022 per publication history.

2021-07provider_update

Provider Update published July 2021 per publication history.