Loading...

    Explore
    • Policy Monitoring
    • Live Policy Feed
    • Billing Codes
    • NPI Medicare & Medicaid
    • Healthcare Providers
    • Health Insurance Payers
    • States
    • Service Lines
    • Taxonomy Codes
    Lookup tools
    • Billing Code Lookup
    • CPT Modifier Lookup
    • Provider Taxonomy Code Lookup
    • Healthcare Provider & Facility Lookup
    • Health Insurance Payer Lookup
    • Payer Contact Directory

    Policy & Benchmark Tools

    • Prior Authorization Lookup
    • Coverage Criteria Lookup
    • Timely Filing Lookup
    • Billing Code Reimbursement Rates
    • Payer Comparison Dashboard
    • Facility Comparison Dashboard
    • All tools

    Company

    • About OpenPayer
    • Data Sources
    • Trek Health
    OpenPayerby Trek Health
    LinkedInYouTube

    © 2026 Trek Health. All rights reserved.

    OpenPayer is built and maintained by Trek Health.

    v1.0.28
    OpenPayerPolicy UpdatesLaboratory/PathologyBlue Cross Blue Shield RI PLA MAAA Prior Auth | Op…
    Ask Trek AI about this page
    CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

    Proprietary Laboratory Analyses (PLA) and Multianalyte Assays with Algorithmic Analyses (MAAA)

    Customize your policy alerts

    Sign up for all Blue Cross Blue Shield - Rhode Island policy alerts

    Know when Blue Cross Blue Shield - Rhode Island releases new policies or updates existing guidance.

    Monitor payer policy activity

    Receive email alerts as soon as relevant payer policies are published or updated.

    Defines prior authorization, medical necessity criteria, coverage stance, and coding guidance for proprietary laboratory (PLA) and MAAA genetic testing services for Blue Cross Blue Shield - Rhode Island members.

    Policy Summary
    PayerBlue Cross Blue Shield - Rhode Island
    PolicyProprietary Laboratory Analyses (PLA) and Multianalyte Assays with Algorithmic Analyses (MAAA)
    Policy CodePolicy N/A
    Change TypeNo material change
    Effective DateJan 5, 2026
    Last ReviewJan 1, 2026
    Next Review DateJan 1, 2026
    Key ActionSubmit prior authorization requests via the BCBSRI online prior authorization tool; fax to Utilization Management only if the test is not found online.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    04/01/2026code grid

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    Required for MA; recommended for Commercialprior auth stance
    Exemption effective 10/01/2025PCP exemption
    Auth per CPT componentpanel testing rule

    Coverage Criteria and Medical Necessity

    General medical necessity for genetic testing

    Covered when ALL of the following are met and/or specific tool criteria are satisfied:

    Carrier screening (preconception or prenatal): One or both individuals have a first- or second-degree relative who is affected; OR one individual is known to be a carrier; OR one or both individuals belong to a population with an elevated carrier rate exceeding an appropriate testing threshold; AND previous carrier screening or targeted testing for the gene variant(s) of interest has not been performed.population carrier rate exceeds a threshold appropriate for testing (exact thresholds defined in online authorization tool)

    Definitions of first- and second-degree relatives provided in policy

    Genetic testing to benefit the individual: Testing is medically necessary when analysis of the individual's germline will benefit the individual and one of the following is met: confirm a suspected diagnosis in a patient with signs/symptoms; identify a causative etiology for a clinical syndrome with multiple possible underlying conditions; or test an asymptomatic individual to determine future disease risk.
    Genetic testing for cancer: Considered medically necessary when testing an asymptomatic patient to determine future cancer risk; OR when therapeutic testing of cancer cells from an affected individual directs targeted treatment based on specific somatic variants.

    Genetic panel testing

    Panel testing coverage considerations

    Panel testing coverage rule: When there is insufficient evidence that a gene or gene variant in a panel improves net health outcomes or guides management, the entire genetic panel test is considered not covered for Medicare Advantage Plans and not medically necessary for Commercial Products.

    Individual CPT-coded panel components are assessed via the attached code grid and the online authorization tool; panel components represented by multiple CPT codes require separate prior authorization entries.

    Coverage for genetic testing services may vary by employer group benefits. Some genetic testing services may be a contract exclusion for self-funded groups when the group has excluded expanded biomarker testing coverage per the state Biomarker Testing Mandate (R.I.G.L. §27-1981). Members and providers should consult the member's Benefit Booklet and the Coding section of the Genetic Testing Services or Proprietary Laboratory Analyses policies to determine whether a specific test is covered with prior authorization, is not medically necessary, or is excluded by contract.

    Genetic testing is considered not covered for Medicare Advantage Plans and not medically necessary for Commercial Products when there is insufficient clinical evidence or strength of recommendation, when test results would not reasonably be used in the management of the patient, or when services are unlikely to impact therapeutic decision-making in clinical care.

    When research does not demonstrate that a specific gene or gene variant reported within a genetic panel can be used to guide treatment decisions and improve net health outcomes, the evidence threshold is not met. In such cases the policy considers the informational value insufficient to support clinical utility and therefore the panel (or the panel component lacking supporting evidence) is considered not covered for Medicare Advantage and not medically necessary for Commercial Products.

    Covered Indications and Tool-Based Criteria

    Carrier screening, diagnostic genetic testing, cancer genetic testing, and therapeutic somatic testing when criteria are met via online authorization tool.

    See the BCBSRI online prior authorization tool and attached code grid for test-specific coverage criteria and authorization requirements.

    Scope: Carrier screening, diagnostic genetic testing, cancer genetic testing, and therapeutic somatic testing are covered when the specific criteria in the BCBSRI online authorization tool and/or applicable policies are satisfied.

    See attached PLA and MAAA code grid for test- and code-specific coverage determinations.

    Authorization and documentation: For services requiring prior authorization, requests should be submitted via the BCBSRI online prior authorization tool by participating providers; if a test is not found in the tool, fax requests to Utilization Management. Panel tests with multiple CPT-coded components must have each CPT code entered and processed independently through the online authorization tool.

    Only the ordering physician may be involved in authorization; laboratories or third parties must not obtain or support authorization on behalf of the ordering physician.

    PLA and MAAA Codes and Coding Guidance

    PLA and MAAA Codes and Coveragemixed
    PLA and MAAA codesSee attached PLA and MAAA code grid for coverage determinations effective 04/01/2026
    Carrier population threshold
    Carrier population thresholdPopulation carrier rate exceeds a threshold appropriate for testing; exact thresholds and test‑specific guidance are defined in the BCBSRI online prior authorization tool.
    Where definedThresholds and test‑specific criteria are available in the BCBSRI online authorization tool used for prior authorization determinations.
    ApplicationApplies to carrier screening (preconception or prenatal) when one or both individuals belong to a population with an elevated carrier rate.

    Prior Authorization, Ordering, and Documentation Requirements

    Prior Authorization

    Prior authorization requirements

    Prior authorization is required for Medicare Advantage plans and is recommended for Commercial Products. For Fully‑Funded Commercial Products only, prior authorization may not be needed when the requesting physician is a BCBSRI‑contracted primary care provider (effective 10/01/2025); the exempt specialties are Internal Medicine, Pediatric Medicine, Family Practice, Obstetrics and Gynecology, Doctor of Osteopathic Medicine, NP/PCP, and PA. Prior authorization continues to be needed for all other Commercial Products, including Self‑Funded and Medicare Advantage plans.

    • Required: Medicare Advantage Plans
    • Recommended: Commercial Products
    • Exemption (Fully‑Funded Commercial only, effective 10/01/2025) for BCBSRI‑contracted PCPs in listed specialties
    Note

    Provider submission and authorization notes

    Preserve the source details for provider-facing instructions: use the BCBSRI online authorization tool for participating providers and fax to Utilization Management at (401) 272‑8885 for others; panel components must be entered per CPT code; prior authorization stance differs by product (required for Medicare Advantage, recommended for Commercial) with a PCP exemption for fully‑funded commercial products effective 10/01/2025.

    Ordering and Authorization Constraints

    Documentation Required

    Ordering and authorization must be handled by the ordering physician

    Only the ordering physician may be involved in authorization, appeal, or other administrative processes related to prior authorization or medical necessity; laboratories are not allowed to obtain clinical authorization or participate in the authorization process on behalf of the ordering physician.

    • Ordering physician must handle authorization, appeals, and related administrative processes
    • Laboratories are prohibited from participating in authorization or obtaining authorization for the ordering physician

    Not Medically Necessary / Not Covered

    Entire genetic panels may be deemed not covered (Medicare Advantage) or not medically necessary (Commercial Products) when there is inadequate evidence that one or more genes or variants in the panel improve net health outcomes or meaningfully guide management. Panel testing can identify variants of uncertain significance that do not change care and may lead to unnecessary interventions; when this utility is not demonstrated by research, the panel is not covered under this policy.

    Key Definitions

    Proprietary Laboratory Analyses (PLA)
    DefinitionProprietary Laboratory Analyses (PLA) are proprietary clinical laboratory analyses represented by PLA codes; they may be sole‑source to a single laboratory or licensed/marketed to multiple providing laboratories.
    IncludesPLA codes include advanced diagnostic laboratory tests (ADLTs) and clinical diagnostic laboratory tests (CDLTs) as defined under PAMA (Protecting Access to Medicare Act).
    Coding precedenceWhen a PLA code is available for a proprietary service, the PLA code takes precedence and the service should not be reported with other CPT codes.
    Regulatory notePLA codes do not require adherence to CPT Category I code criteria or AMA review for clinical utility and may or may not be FDA approved.
    MAAA (Multianalyte Assays with Algorithmic Analyses)
    Definition

    Background and Scope

    Proprietary Laboratory Analyses (PLA) codes identify laboratory tests — including advanced or specialty assays — that may be proprietary to a single laboratory or manufacturer. PLA and similar multianalyte algorithmic tests (MAAAs) can provide unique, lab-specific reports but may not follow standard Category I CPT processes. Because PLA/MAAA tests can be unique to one provider and may report results not generalizable across settings, the policy treats these proprietary identifiers as distinct test entities when assessing coverage and clinical utility.

    Policy Summary
    PayerBlue Cross Blue Shield - Rhode Island
    PolicyProprietary Laboratory Analyses (PLA) and Multianalyte Assays with Algorithmic Analyses (MAAA)
    Policy CodePolicy N/A
    Change TypeNo material change
    Effective DateJan 5, 2026
    Last ReviewJan 1, 2026
    Next Review DateJan 1, 2026
    Key ActionSubmit prior authorization requests via the BCBSRI online prior authorization tool; fax to Utilization Management only if the test is not found online.
    SourceLink
    On This Page
    Coverage Criteria and Medical NecessityCovered Indications and Tool-Based CriteriaPLA and MAAA Codes and Coding GuidancePrior Authorization, Ordering, and Documentation RequirementsOrdering and Authorization ConstraintsNot Medically Necessary / Not CoveredKey DefinitionsBackground and Scope
    Not covered / not medically necessary:
    Genetic testing services are not covered for Medicare Advantage Plans and not medically necessary for Commercial Products when evidence is insufficient, results would not reasonably be used in management, or services are unlikely to impact therapeutic decision-making. When there is insufficient research that a gene or gene variant in a panel can be used to manage treatment and improve net health outcomes, the entire panel is considered not covered (Medicare Advantage) and not medically necessary (Commercial).

    Coverage may also vary by contract or self-funded group per related policies.

    • Use online tool or fax as specified
    • Panel testing: enter each CPT code separately
    • Prior auth: required for Medicare Advantage; recommended for Commercial; PCP exemption for certain fully‑funded commercial specialties
    Note

    How to submit prior authorization

    Submit prior authorization requests using the BCBSRI online prior authorization tool if you are a BCBSRI‑participating provider. If the test is not found in the online tool or you are not a participating provider, fax the prior authorization request to Utilization Management at (401) 272‑8885.

    • Use BCBSRI online prior authorization tool (participating providers)
    • Fax requests and tests not listed in the tool to Utilization Management at (401) 272‑8885 (non‑participating providers or absent tests)
    Documentation Required

    Panel testing requires individual CPT authorization

    Panel testing represented by multiple CPT codes requires prior authorization for each component; each individual CPT code must be entered into and processed independently through the online authorization tool.

    • Enter and process each CPT component of a panel separately in the online authorization tool
    Denial Risk

    Laboratory involvement in authorization prohibited

    A laboratory or any third party may not obtain, facilitate, or support the prior authorization process on behalf of the ordering physician; such actions are a policy violation and may result in severe action up to termination from the BCBSRI provider network and denial of services as the financial liability of the participating laboratory.

    • Labs/third parties cannot obtain or support authorization or appeals for ordering physicians
    • Violations may lead to termination from the BCBSRI network and denial of unauthorized services billed to the laboratory
    Multianalyte Assays with Algorithmic Analyses (MAAA/MAAAs) utilize multiple assay results (molecular, FISH, non‑nucleic analytes such as proteins) combined with algorithmic analysis and are typically reported as numeric score(s) or probabilities.
    UniquenessMAAAs are typically unique to a single clinical laboratory or manufacturer.
    Data usedAlgorithmic analysis may incorporate assay results and other patient information when producing reported scores or probabilities.
    First‑ and second‑degree relatives
    First‑degree relativeBiological parent, brother, sister, or child.
    Second‑degree relativeBiologic grandparent, aunt, uncle, niece, nephew, grandchild, or half‑sibling.
    Use in criteriaDefinitions apply to carrier screening criteria where one or both individuals have a first‑ or second‑degree relative who is affected.