DraftBlue Cross Blue Shield - Rhode IslandPolicy N/A

Prior Authorization via Web-Based Tool for Durable Medical Equipment (DME)

This policy governs the prior authorization process and medical necessity criteria for durable medical equipment (DME) requests submitted to Blue Cross Blue Shield of Rhode Island; it affects providers requesting DME authorization for Medicare Advantage and Commercial members.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyPrior Authorization via Web-Based Tool for Durable Medical Equipment (DME)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateNov 1, 2025

Next Review DateN/A

Key ActionSubmit prior authorization requests for DME via the BCBSRI online prior authorization tool (or fax for non‑participating providers) with required clinical documentation to support medical necessity.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1web-based prior authorization tool referenced

10/1/2025exemption date for certain fully-funded commercial PCP-authored requests

7listed PCP specialties eligible for exemption

6policies referenced in Related Policies section

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Coverage & General Medical Necessity

Medical necessity (general)

Durable medical equipment is considered medically necessary when the applicable criteria in the BCBSRI online authorization tool are met.

General medical necessity: Authorization and coverage require that the specific InterQual criteria (or CMS NCD/LCD for Medicare Advantage when applicable) listed in the BCBSRI online authorization tool are met for the requested DME item.

See online authorization tool and attached coding grid for item-specific criteria.

The attached coding list is intended to identify items that require authorization; however, the absence of a code from the attached list does not imply coverage. For Medicare Advantage members, applicable CMS National or Local Coverage Determinations apply and Noridian references for Jurisdiction A are used where indicated. Providers must refer to the BCBSRI online authorization tool and the Coverage section of this policy for the item-specific medical necessity criteria and coding guidance.

If services are determined to be not medically necessary (or are non-covered under the member's benefit), the provider may not charge the member for those services unless the member has been informed and has agreed in writing in advance to continue the service at their own expense in accordance with applicable informed consent and notice rules and the provider's participation agreement.

Coding and Coverage Lists

Covered codes (per attached grid/link)mixedCovered

No codes listed

Noridian Noncovered Items / LCD referencesmixedNot Covered

No codes listed

Not applicable — coding thresholds and numeric intervals (placeholder)

Coding thresholdsNot applicable — no numeric thresholds specified in this policy; refer to the attached coding grid in the online authorization tool for item-specific rules.

Covered codes listedCovered codes are provided in the attached coding grid/link; presence of a code there does not replace meeting the applicable medical criteria.

Noridian/LCD codesNoridian Local Coverage Determination (Jurisdiction A) noncovered items are referenced for Medicare Advantage; see coding attachments.

Item-Specific Medical Necessity Criteria

DME item medical necessity

Item-specific medical necessity criteria are provided in the BCBSRI online authorization tool (InterQual generally; CMS NCD/LCD when applicable).

Item-level criteria: The requested DME item meets the specific InterQual criteria displayed in the BCBSRI online authorization tool, or meets applicable CMS National or Local Coverage Determinations for Medicare Advantage members; for items listed in Related Policies, BCBSRI-specific criteria apply.

Providers must reference the online authorization tool and the attached coding grid/link for the exact item criteria and required documentation.

Prior Authorization and Submission Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for Medicare Advantage plans and for many Commercial products. Failure to obtain authorization when required may result in denial of the request or claim adjustments.

Required for Medicare Advantage plans
Required for non-exempt Commercial products (including many fully-funded and self-funded products unless exempted below)

Billing Rule

Prior Authorization Submission Requirement

Requests for durable medical equipment (DME) and other services that require authorization must be submitted via the BCBSRI online prior authorization tool (available to participating providers). Non-participating providers or others unable to access the online tool should fax authorization requests to Utilization Management at (401) 272-8885. The online tool is the authoritative submission channel and contains the medical criteria used to evaluate requests.

Use the BCBSRI online prior authorization tool for participating providers
Fax requests to Utilization Management at (401) 272-8885 for non-participating providers

Note

Use Online Tool for Medical Criteria

Medical necessity criteria used to support authorizations are those published in the BCBSRI online authorization tool. InterQual criteria are used generally; when applicable for Medicare Advantage members, CMS National and Local Coverage Determinations (NCDs/LCDs) are used. For certain related policies, BCBSRI-specific medical criteria may apply as noted in those policies.

InterQual criteria are the primary source in the online tool
CMS NCDs/LCDs are used for Medicare Advantage when applicable
BCBSRI-specific criteria apply for policies listed in Related Policies

Step Therapy

Step Criteria Located in Online Tool

Step therapy rules and any step criteria applied to authorization requests are located within the BCBSRI online prior authorization tool. Providers must consult the online tool to see required prior steps or alternative therapies that must be tried and documented.

Step therapy requirements (if any) are published in the online authorization tool
Providers must document prior steps per the tool to support medical necessity

Note

Exemption for Certain Fully-Funded Commercial PCPs

Effective 10/1/2025, an exemption applies for certain Fully-Funded Commercial Products when the requesting provider is a BCBSRI contracted primary care provider in the listed specialties; prior authorization may not be required for those requests under that narrow exemption. Prior authorization continues to be required for all other Commercial Products (including self-funded) and for Medicare Advantage.

Exempt specialties (credentialed as PCPs): Internal Medicine; Pediatric Medicine; Family Practice; Obstetrics and Gynecology; Doctor of Osteopathic Medicine; Physician Assistant (PA); Nurse Practitioner (NP)/PCP
Exemption applies only to Fully-Funded Commercial Products and only when the requesting clinician is a BCBSRI contracted PCP
Authorization remains required for Self-Funded Commercial Products and Medicare Advantage

Denial Risk

Authorization Required for Many Requests

Authorization obtained through the online tool (or fax entry for non-participating providers) must be completed before services are rendered when required. Failure to obtain prior authorization may result in denial or retroactive claim adjustment.

Incomplete or absent prior authorization may cause denials or claim adjustments
Use the online tool to confirm authorization status and view required documentation

Clinical Documentation Requirements

Documentation Required

Submit required clinical documentation via online tool or fax for non‑participating providers

Providers must submit the required clinical documentation to support medical necessity through the BCBSRI online authorization tool; non‑participating providers may fax documentation/requests to Utilization Management at (401) 272‑8885 to complete the authorization process.

Rental, Purchase, and Replacement Rules

Item / Rule	Details
Policy statement	This policy references the BCBSRI coding grid (link) for covered DME items but does not specify rental versus purchase rules within the document text; providers must refer to the online coding grid and item‑specific criteria in the BCBSRI authorization tool for any billing or rental/purchase determinations.
Action for providers	Use the attached coding grid/link and the BCBSRI online authorization tool to determine whether an item is covered and to obtain any item‑specific instructions (including whether rental or purchase is appropriate), since rental/purchase rules are not defined in this policy.
Medicare Advantage / Noridian note	Noridian noncovered items and applicable CMS NCD/LCDs remain applicable for Medicare Advantage members; refer to the coding grid and referenced LCDs for coverage and billing guidance.

Replacement (placeholder)

Replacement guidance placeholderNo replacement-specific policy text provided in this document; refer to item-level rules in the online authorization tool or coding grid.

Coding gridReplacement or replacement-interval rules, if any, are defined in the attached coding grid/link referenced in the policy.

Provider actionUse the BCBSRI online authorization tool to verify any replacement/upgrade eligibility and required documentation.

Definitions and Reference Terms

InterQual (definition)

DefinitionInterQual — a set of clinical criteria referenced by BCBSRI in the online authorization tool to determine medical necessity for DME.

Where usedInterQual criteria are generally used to determine medical necessity and are found in the BCBSRI online authorization tool.

Related guidanceFor items listed in Related Policies, BCBSRI-specific criteria (not InterQual) may apply; check the Related Policies list.

CMS NCD / LCD (definition)

DefinitionCMS NCD/LCD — Centers for Medicare & Medicaid Services National and Local Coverage Determinations used to determine medical necessity for Medicare Advantage members.

Noridian LCDLocal Coverage Determination from Noridian Healthcare Solutions, Jurisdiction A, and Noridian Jurisdiction A Noncovered Items are referenced for Medicare Advantage.

Where foundCMS NCDs and LCDs are available in the BCBSRI online authorization tool and are applied when applicable for Medicare Advantage plan determinations.

This policy uses clinical criteria from the BCBSRI online authorization tool to determine medical necessity for durable medical equipment, generally relying on InterQual criteria. For Medicare Advantage members, applicable CMS National and Local Coverage Determinations (including Noridian LCDs where relevant) are referenced and applied when determining coverage.

Noncovered Items

For Medicare Advantage members, Noridian Healthcare Solutions Jurisdiction A guidance applies where indicated. This includes applicable Local Coverage Determinations and Noridian 'Noncovered Items' lists for Jurisdiction A; those noncovered determinations remain in effect for Medicare Advantage members as referenced in this policy and must be followed when evaluating coverage.

Policy Revision History

2025-11-01policy_effectiveLatest

Policy effective date established as November 1, 2025.

2025-08-06policy_reviewed

Policy last reviewed on August 6, 2025.

2025-10-01policy_change

Effective October 1, 2025, Fully-Funded Commercial Products may be exempted from prior authorization when the requesting physician is a BCBSRI contracted primary care provider of listed specialties.

2025-01-01provider_communications

Policy referenced in Provider Updates published in January/February/September/October 2025 (Provider Update listings include 2025 issues).