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Prior Authorization of Services, Treatments or Procedures
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This draft policy governs BCBSRI's prior authorization request process for certain medical procedures using the BCBSRI online prior authorization tool and specifies when prior authorization is required or exempted for providers and plan types.
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.
Prior authorization is required for Medicare Advantage Plans and recommended for Commercial Products.
Coverage & Medical Necessity Criteria
Medical necessity determination
Medical procedures are considered medically necessary when the BCBSRI online prior authorization tool criteria are met.
Uses InterQual criteria generally; CMS NCD/LCD criteria are used when applicable for Medicare Advantage Members; for certain related policies BCBSRI-specific criteria are used.
Prior authorization and PCP exemptions
Prior authorization requirements vary by plan and by whether the requesting provider is a BCBSRI contracted PCP.
Requests for medical procedures should be submitted via the BCBSRI online prior authorization tool (participating providers) or faxed to Utilization Management at 401-272-8885 for non‑participating providers.
Specialties included: Internal Medicine; Pediatric Medicine; Family Practice; Obstetrics and Gynecology; Doctor of Osteopathic Medicine; NP/PCP; PA.
Specialties included: Internal Medicine; Pediatric Medicine; Family Practice; NP/PCP; PA. See attached code grid for applicable services.
If the complexity of a procedure is unknown prior to the service, a retrospective authorization must still be obtained.
Services that are outside the scope of the BCBSRI online prior authorization tool will not be authorized through this system. Examples include dental services rendered in the outpatient setting. For coverage determinations, billing guidance, or to request authorization for services not handled in the online tool, refer to the individual medical policies posted on the BCBSRI web site.
If a service is determined to be not medically necessary or is a non-covered benefit, the provider may not bill the member for that service unless the member was informed and provided written agreement in advance to continue the treatment at their own expense. Member benefits and eligibility are governed by the member’s subscriber agreement or certificate and the employer agreement, which supersede this policy; contact the provider call center for member-specific benefit information.
Code Grid and Coding Guidance
| see attached grid/link | The policy references an attached code grid in the online tool listing codes covered when applicable medical criteria are met. |
What Providers Must Do
Prior authorization required for Medicare Advantage; PCP exemptions for some Commercial plans
Prior authorization is required for Medicare Advantage Plans and is recommended for Commercial Products. 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 10/1/2025) — see the listed specialties. An additional exemption (effective 5/15/2025) also may remove prior authorization for certain services when the requesting physician is a BCBSRI Contracted PCP; see the attached code grid for applicable services. If a service requiring prior authorization is performed urgently or its complexity is unknown prior to the service, a retrospective authorization must be obtained through the online tool.
- Exempted specialties (10/1/2025 list): Internal Medicine; Pediatric Medicine; Family Practice; Obstetrics and Gynecology; Doctor of Osteopathic Medicine; NP/PCP; PA.
- Exempted specialties (5/15/2025 list): Internal Medicine; Pediatric Medicine; Family Practice; NP/PCP; PA.
Clinical criteria sources: InterQual and CMS NCD/LCD
Medical necessity for requested services is determined using InterQual criteria in the BCBSRI online authorization tool. When applicable for Medicare Advantage members, CMS National and Local Coverage Determinations (NCD/LCD) criteria are used. For related policies listed in the Related Policies section, BCBSRI‑specific medical criteria may apply.
How to submit prior authorization requests
Submit prior authorization requests via the BCBSRI online prior authorization tool (available only to participating providers). Providers who are not participating should fax requests to Utilization Management at 401‑272‑8885. The online tool lists procedures and the attached code grid for services requiring prior authorization.
- Online tool URL referenced in policy for provider access.
- Non‑participating providers must fax to Utilization Management at 401‑272‑8885.
Obtain retrospective authorization for urgent or unanticipated‑complexity services
If a service that requires prior authorization is performed on an urgent basis, obtain a retrospective authorization through the BCBSRI online tool. The same retrospective authorization requirement applies when the complexity of a procedure is unknown prior to the service; failure to obtain required authorization may lead to denial or claims processing issues.
Background
This policy describes the administrative process for submitting prior authorization requests for certain medical procedures using the BCBSRI online prior authorization tool. Medical necessity determinations within the tool are based on established clinical criteria (for example, InterQual and, when applicable for Medicare Advantage members, CMS NCD/LCD). The policy also defines when prior authorization is required by plan type and notes provider-specific exemptions (for example, exemptions that apply to BCBSRI-contracted primary care providers effective on the dates specified in the policy).
Definitions & Key Terms
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