CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Treatment of Medical and Surgical Complications Following Non‑covered Services

Defines reimbursement intent and coverage stance for medical and surgical complications that arise from non-covered procedures (including cosmetic procedures) for BlueCHiP for Medicare and Commercial members of BCBSRI.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyTreatment of Medical and Surgical Complications Following Non‑covered Services

Policy CodePolicy N/A

Change TypeNo material change

Effective DateApr 1, 2014

Next Review DateN/A

Key ActionIssue an Advance Notice of Non-coverage (ANN) to commercial members when services are non-covered or not medically necessary.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2014-04-01effective date

2018-02-06policy last updated

NoneMedical criteria specified

NonePrior authorization required

Coverage Criteria — Treatment of Complications from Non‑Covered Services

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyTreatment of Medical and Surgical Complications Following Non‑covered Services

Policy CodePolicy N/A

Change TypeNo material change

Effective DateApr 1, 2014

Next Review DateN/A

Key ActionIssue an Advance Notice of Non-coverage (ANN) to commercial members when services are non-covered or not medically necessary.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Provider Actions — Prior Authorization, ANN, and Related Notices

Prior Authorization

Prior Authorization: No prior authorization requirements are listed for this policy.

Note

BlueCHiP for Medicare — Pre‑service determination required

BlueCHiP for Medicare — Pre‑service determination required: The Advanced Beneficiary Notice (ABN) is not used for services provided under the BlueCHiP for Medicare program. If a provider believes a service will not be covered, the provider must request a pre‑service organization determination from BCBSRI before rendering the service. If the provider does not request a pre‑service determination and proceeds to render the service, the provider will be liable for the cost of the services. BlueCHiP for Medicare members are held harmless. Pre‑service determinations may be obtained by contacting Blue Cross & Blue Shield of Rhode Island or the plan's designated vendor. See the Prior Authorization section for details.

Prior Authorization

Advance Notice of Non‑coverage (Commercial)

Advance Notice of Non‑coverage (ANN) — Commercial products: The ANN (also called an ABN) is a written notice provided to commercial members to indicate that a service is not expected to be covered by the member's insurance. Providers who must issue an ANN include physicians, laboratories, hospitals (inpatient/outpatient), durable medical equipment (DME) providers, skilled nursing facilities (SNF), hospice providers, and home health providers.

Use an ANN to notify members in advance when services are non‑covered or not medically necessary.
Claims filed with GA, GU, or GX modifiers may be billed as member liability when an appropriate ANN has been completed.

Note

ANN — When to issue

When to complete an ANN for commercial members: Providers should complete an ANN to notify commercial members in advance of: initiation of services (start of a new encounter, plan of care, or treatment), reduction of services (decrease in frequency or duration of a component of care), or termination of services (discontinuation of items/services).

Denial Risk

Provider obligations and member liability (Commercial)

Provider liability and member notification: Providers must complete and give an ANN when applicable to avoid unexpected member liability. Members may not be held liable for services that are bundled into another covered service or otherwise excluded from member liability under plan rules; follow plan guidance and modifiers (GA/GU/GX) when applicable.

Definitions

Complication

DefinitionAn adverse event that occurs in the course of another condition or during its treatment which may require medical and/or surgical therapy.

OriginMay be of either medical or surgical origin and can modify the course of the original condition.

Impact on careMay require medical and/or surgical therapy to correct functional impairment or alter the treatment plan.

Relation to non-covered proceduresTreatment of complications may be medically necessary even when the precipitating procedure was cosmetic or otherwise non-covered.

Cosmetic services

DefinitionServices provided to improve an individual’s physical appearance from which no significant improvement in physiologic function can be expected.

Physiologic benefitEmotional and/or psychological improvement alone does not constitute improvement in physiologic function.

Coverage implicationCosmetic services are considered non-covered when they do not result in significant physiologic improvement.

ExceptionsProcedures that also provide therapeutic physiologic benefit (e.g., treatment of severe burns) may be medically necessary even if they have cosmetic effects.

OpenPayer

Treatment of Medical and Surgical Complications Following Non‑covered Services

Coverage Criteria — Treatment of Complications from Non‑Covered Services

Coding

Provider Actions — Prior Authorization, ANN, and Related Notices

Background

Definitions