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Prior Authorization of Services, Treatments or Procedures
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Defines BCBSRI's prior authorization request process (online tool and fax alternative) for certain medical procedures and which provider types/situations require or are exempt from prior authorization. Affects providers requesting authorization for Medicare Advantage and Commercial products.
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 & Medical Necessity
General medical necessity
Covered when applicable BCBSRI prior authorization criteria are met and benefits permit
Benefits may vary by group/contract; refer to the appropriate Benefit Booklet, Evidence of Coverage, or Subscriber Agreement for applicable coverage.
Contracted PCP exemptions
Exemptions to prior authorization for certain provider types and products (effective dates as noted)
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.
Participating providers use the online prior authorization tool; non‑participating providers should fax requests to Utilization Management at 401‑272‑8885.
Services such as dental services rendered in the outpatient setting are excluded from authorization through the BCBSRI online prior authorization tool. Providers should refer to the individual BCBSRI policies posted on the web for coverage and submission instructions for these services.
If services are determined to not be medically necessary (or are medically necessary but are non-covered benefits), providers may not charge the member for those services unless the provider has informed the member and obtained the member’s written agreement in advance to continue the treatment at their own expense. Refer to the member’s subscriber agreement, employer agreement, and the provider participation agreement for applicable provisions.
Provider Submission, Criteria Sources, and Risk
Prior authorization required (with limited PCP exemptions and retrospective auth)
Prior authorization is required for Medicare Advantage members and recommended for Commercial Products. Effective 10/1/2025 (Fully‑Funded Commercial Products only) and effective 5/15/2025 for certain services, prior authorization may not be needed when the requesting physician is a BCBSRI contracted primary care provider; applicable specialties and services are listed in the policy and attached code grid. If a service that requires prior authorization is performed on an urgent basis, or the complexity is unknown prior to the service, a retrospective authorization must be obtained through the online tool.
- Effective 10/1/2025 exemption applies to Fully‑Funded Commercial Products when the requesting physician is a BCBSRI Contracted Primary Care Provider (listed specialties).
- Effective 5/15/2025 exemption applies for certain services when the requesting physician is a BCBSRI Contracted Primary Care Provider; see attached code grid.
- Retrospective authorization required for urgent services or when procedure complexity is unknown.
Sources of medical necessity criteria (InterQual; CMS NCD/LCD)
Medical necessity determinations use InterQual criteria available in the BCBSRI online authorization tool. For Medicare Advantage members, applicable CMS National and Local Coverage Determinations (NCD/LCD) criteria are used; for policies listed in Related Policies, BCBSRI medical criteria apply.
- InterQual criteria: proprietary clinical criteria in the online tool.
- CMS NCD/LCD apply for Medicare Advantage when relevant.
- BCBSRI medical criteria used for policies listed in Related Policies.
How to submit prior authorization requests
Participating providers must submit prior authorization requests via the BCBSRI online prior authorization tool (available to participating providers only). Non‑participating providers must fax prior authorization requests to Utilization Management at 401‑272‑8885.
- Online tool: available only to participating providers (link provided in policy).
- Fax alternative for all other providers: 401-272-8885.
Denial risk if prior authorization not obtained; retrospective authorization required
Failure to obtain prior authorization for services that require it may result in denial of the service. If services requiring prior authorization are performed urgently or when complexity is unknown, providers must obtain retrospective authorization through the online tool to avoid denial.
- Denial risk for services performed without required prior authorization.
- Retrospective authorization via the online tool is required for urgent or unknown‑complexity procedures.
Referenced Codes
| see attached grid | The document references an attached code grid listing codes covered when applicable medical criteria are met. |
Policy Background
This policy addresses the administrative prior authorization process and the use of the BCBSRI online prior authorization tool rather than the clinical details of individual treatments. Medical necessity determinations referenced by this policy are made using the criteria available in the online tool (for example, InterQual criteria) and, where applicable for Medicare Advantage members, CMS National and Local Coverage Determinations.
The policy clarifies which services require prior authorization and notes where authorizations are not provided by this system (for example, outpatient dental services). It also explains submission methods and operational expectations for participating and non‑participating providers when prior authorization is required.
Key Definitions
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