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Prior Authorization of Services, Treatments or Procedures
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Defines BCBSRI's prior authorization requirements and process for certain medical procedures, including which providers and products require authorization and how requests should be submitted.
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.
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.
Coverage Criteria
General medical necessity and submission criteria
Covered when ALL of the following are met:
See attached code grid for applicable services; online tool is primary submission route.
InterQual and CMS NCD/LCD determinations are applied within the online tool.
If a service requiring prior authorization is performed urgently or complexity is unknown, a retrospective authorization must be obtained via the online tool.
PCP-contracted exemption
Prior authorization may not be required for certain services when ALL of the following apply:
Included specialties: Internal Medicine; Pediatric Medicine; Family Practice; Obstetrics and Gynecology; Doctor of Osteopathic Medicine; NP/PCP; PA (see policy).
Effective dates and product scope
- Fully-Funded Commercial Products (effective 10/1/2025): Exemption applies for Fully-Funded Commercial Products starting 10/1/2025 when the requesting physician is a BCBSRI-contracted PCP in an included specialty.
Prior authorization continues to be needed for all other Commercial Products, including Self-Funded and Medicare Advantage Plans.
- General exemption (effective 5/15/2025): Exemption applies starting 5/15/2025 for certain services when the requesting physician is a BCBSRI-contracted PCP in an included specialty.
See attached code grid for applicable services.
Dental services rendered in the outpatient setting are excluded from authorization via the BCBSRI online prior authorization tool. Providers should refer to the individual BCBSRI dental policies on the web for coverage and submission instructions for outpatient dental services.
If services are determined to not be medically necessary (or are medically necessary but non-covered benefits), providers may not charge the member for those services unless the member was informed and provided written agreement in advance to pay out-of-pocket. Benefits and eligibility are determined by the member’s subscriber agreement, member certificate, or employer agreement, which supersede this policy.
Coding and Authorization Codes
| Attached grid | Codes listed in the attached code grid available via the BCBSRI link; these are covered when applicable medical criteria are met. |
| Attached grid | Codes listed in the attached code grid available via the BCBSRI link; these are covered when applicable medical criteria are met. |
Provider Actions and Submission Requirements
Prior authorization requirement
Prior authorization is required for Medicare Advantage Plans and is recommended for Commercial Products. Certain procedure codes in the attached code grid are subject to authorization when applicable medical criteria are met; submit requests via the BCBSRI online prior authorization tool or by fax if you are a non‑participating provider.
- Required: Medicare Advantage Plans.
- Recommended: Commercial Products.
- Applicable codes listed in the attached code grid (see policy link).
PCP-contracted exemption (effective dates)
Exemptions from prior authorization apply when the requesting clinician is a BCBSRI contracted Primary Care Provider in the listed specialties. Effective 5/15/2025 this exemption applies as stated; for Fully‑Funded Commercial Products the exemption is effective 10/1/2025.
- Included specialties for 10/1/2025 exemption: Internal Medicine; Pediatric Medicine; Family Practice; Obstetrics and Gynecology; DO; NP/PCP; PA.
- Included specialties for 5/15/2025 exemption: Internal Medicine; Pediatric Medicine; Family Practice; NP/PCP; PA.
Clinical criteria used in authorization tool
Medical necessity determinations in the online authorization tool use InterQual criteria; for Medicare Advantage Members, CMS National and Local Coverage Determinations (NCD/LCD) are applied where applicable.
- InterQual criteria implemented in the online prior authorization tool.
- CMS NCD/LCD used when applicable for Medicare Advantage Members.
Submission method — online tool primary; fax for non‑participants
Submit prior authorization requests through the BCBSRI online prior authorization tool (available only to participating providers). Non‑participating providers must fax requests to Utilization Management at 401‑272‑8885.
- Online tool is the primary submission route for participating providers.
- Fax submissions (non‑participating providers): 401-272-8885.
Denial and retrospective authorization risks
Failure to obtain required prior authorization may result in denial; services performed urgently or when procedure complexity is unknown require retrospective authorization if prior approval was not obtained.
- Denial risk for services requiring prior authorization when authorization was not obtained.
- Urgent or unknown‑complexity services performed without prior authorization require retrospective authorization via the online tool.
Definitions
Background
This policy governs the administrative prior authorization process for certain medical procedures using the BCBSRI online prior authorization tool rather than establishing clinical treatment standards. Where applicable, the online tool applies InterQual criteria and CMS NCD/LCD determinations to assess medical necessity. Separate related clinical policies contain procedure-specific coverage statements; this document describes the administrative submission, review, and authorization workflow.
Revision History
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.
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.
Policy effective date established as 2026-09-01.
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