Blue Cross Blue Shield - Rhode Island Coverage Criteria
- Blue Cross Blue Shield - Rhode Island prior authorization
- Blue Cross Blue Shield - Rhode Island timely filing
- All Blue Cross Blue Shield - Rhode Island policy updates
Latest Blue Cross Blue Shield - Rhode Island coverage criteria updates25
- Coverage CriteriaClinical/Medical PolicyEff. 2026-10-01Epidural Steroid Injections (ESIs) for Pain ManagementCommercial product coverage criteria and coding guidance for epidural steroid injections (interlaminar and transforaminal; cervical, thoracic, lumbar/sacral) when medical criteria in the payer's online authorization tool are met. Applies to participating providers submitting prior authorization for commercial members; Medicare Advantage has a separate policy.All Blue Cross Blue Shield - Rhode Island updates
- Coverage CriteriaReimbursement/Payment PolicyEff. 2026-10-01Prior Authorization for Durable Medical Equipment (DME)Defines prior authorization requirements and medical necessity criteria for durable medical equipment (DME) for Blue Cross Blue Shield - Rhode Island members, affecting participating providers and other requestors submitting authorization requests.All Blue Cross Blue Shield - Rhode Island updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-09-01Whole Exome and Whole Genome Sequencing for Diagnosis of Genetic DisordersDefines medical necessity, prior authorization, and coverage criteria for whole exome sequencing (WES) and whole genome sequencing (WGS), including rapid testing and specific proprietary Genomic Unity® Exome Plus analyses, for Medicare Advantage and Commercial products of BCBSRI.All Blue Cross Blue Shield - Rhode Island updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-01Biomarker Testing / Genetic & Molecular Testing Coverage CriteriaGoverns state-mandated coverage, medical necessity, and prior authorization requirements for biomarker and genetic/molecular tests for BCBSRI Commercial Products and Medicare Advantage Plans.All Blue Cross Blue Shield - Rhode Island updates
- Coverage CriteriaReimbursement/Payment PolicyEff. 2026-07-01Prior Authorization for Durable Medical Equipment (DME)This policy governs prior authorization requirements and the use of medical necessity criteria for durable medical equipment for Blue Cross Blue Shield - Rhode Island members, affecting providers requesting DME for Medicare Advantage and Commercial products.All Blue Cross Blue Shield - Rhode Island updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-06-01Bariatric Surgery — SADI-S and Other Procedures Coverage CriteriaDefines medical necessity, coverage stance, and prior authorization requirements for single anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S) and lists bariatric procedures considered not covered or not medically necessary for Medicare Advantage and Commercial products.All Blue Cross Blue Shield - Rhode Island updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-06-01Genetic Testing ServicesDefines medical necessity, prior authorization, and coverage stance for genetic and molecular testing services for BCBSRI Medicare Advantage and Commercial products, including panel testing and multianalyte assays.All Blue Cross Blue Shield - Rhode Island updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-06-01Genetic Testing ServicesPolicy governing medical necessity, coverage, and prior authorization requirements for genetic and molecular testing services for BCBSRI members (Medicare Advantage and Commercial products). Applies to ordering providers and laboratories interacting with BCBSRI.All Blue Cross Blue Shield - Rhode Island updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-06-01Oral Nutrition (non-prescription enteral formulas and low-protein foods)Governs coverage for non-prescription oral nutritional formulas, low-protein foods, and special medical formulas for home use for commercial members when ordered by a physician for specified conditions. Affects providers submitting prior authorization and members seeking reimbursement under Blue Cross & Blue Shield of Rhode Island commercial products.All Blue Cross Blue Shield - Rhode Island updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-06-01Prior Authorization of DrugsDefines drugs that require prior authorization for BCBSRI Medicare Advantage and Commercial medical plans, directs providers to the Drug Management vendor (Prime Therapeutics/GatewayPA) for clinical criteria and submission, and lists procedural notes about coding and settings where PA does not apply.All Blue Cross Blue Shield - Rhode Island updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-06-01Proprietary Laboratory Analyses (PLA) and Multianalyte Assays with Algorithmic Analyses (MAAA)Defines coverage, medical necessity criteria, and prior authorization requirements for proprietary genetic and multianalyte laboratory tests (PLA/MAAA) for BCBSRI members, applying to Medicare Advantage and Commercial Products.All Blue Cross Blue Shield - Rhode Island updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-06-01Tonic Motor Activation (TOMAC) for Restless Legs Syndrome — Coverage CriteriaThis draft policy governs coverage and coding for tonic motor activation (TOMAC), a bilateral peroneal nerve stimulation device for adults with primary moderate-to-severe restless legs syndrome (RLS) refractory to medication, and applies to Medicare Advantage and Commercial products of Blue Cross Blue Shield - Rhode Island.All Blue Cross Blue Shield - Rhode Island updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-06-01Tonic Motor Activation (TOMAC) for Restless Legs Syndrome — Coverage CriteriaPolicy governing coverage determinations for bilateral peroneal nerve stimulation (TOMAC) to treat primary restless legs syndrome (RLS) refractory to medication for Blue Cross Blue Shield - Rhode Island members.All Blue Cross Blue Shield - Rhode Island updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-04-01Genetic Testing Services (Genetic & Molecular Testing Coverage Criteria)Policy governing medical necessity, prior authorization, and coverage determinations for genetic and molecular testing services for BCBSRI members, affecting ordering providers and participating laboratories.All Blue Cross Blue Shield - Rhode Island updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-04-01Infertility Services (ART, IUI/ICI, IVF, donor gametes, preservation)Governs coverage and medical necessity criteria for infertility treatments including artificial insemination (IUI/ICI), in vitro fertilization (IVF) and related services for members of Blue Cross Blue Shield - Rhode Island under the Standard Infertility Services Benefit; notes differences for self-funded expanded plans.All Blue Cross Blue Shield - Rhode Island updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-04-01Minimally Invasive Procedures for Back Pain (including basivertebral nerve ablation)Medical coverage criteria and policy stance for minimally invasive interventional procedures to treat low back pain, including basivertebral nerve ablation and various intradiscal and disc decompression techniques, for Blue Cross Blue Shield - Rhode Island members.All Blue Cross Blue Shield - Rhode Island updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-04-01Surgical Treatment of Snoring and Obstructive Sleep Apnea SyndromeDefines medical necessity, prior authorization, and coverage stance for various surgical procedures for adult and pediatric OSA and snoring for Blue Cross Blue Shield - Rhode Island commercial products and Medicare Advantage where noted.All Blue Cross Blue Shield - Rhode Island updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-03-01Low-Level Laser Therapy (Photobiomodulation) — Coverage CriteriaDefines coverage stance for low-level laser therapy (also called photobiomodulation) for Medicare Advantage and commercial products, specifying covered indication(s) and noncovered/not medically necessary indications.All Blue Cross Blue Shield - Rhode Island updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-03-01Remote Intraoperative Neurophysiologic (IONP) MonitoringThis policy governs coverage and medical necessity criteria for remote intraoperative neurophysiologic monitoring services (IONP/IONM) provided from outside the operating room for Blue Cross Blue Shield of Rhode Island members.All Blue Cross Blue Shield - Rhode Island updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-01-11Long Term Acute Care Hospital (LTACH) Admission and Transition of Care CriteriaDefines medical necessity criteria, prior authorization expectations, and transition/discharge conditions for admission to and transition from long-term acute care hospitals for BCBSRI members under Medicare Advantage and Commercial products.All Blue Cross Blue Shield - Rhode Island updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-01-10Enhanced External Counterpulsation (EECP) Coverage CriteriaCoverage guidelines for outpatient use of Enhanced External Counterpulsation (EECP) for Medicare Advantage and Commercial members; defines medical necessity, prior authorization guidance, coding, and device background.All Blue Cross Blue Shield - Rhode Island updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-01-10Microvolt T‑Wave Alternans (MTWA) Testing — Coverage CriteriaPolicy governing coverage and medical necessity of MTWA testing (spectral analytic method) for risk assessment of ventricular arrhythmias and sudden cardiac death for Blue Cross & Blue Shield of Rhode Island products, distinguishing Medicare Advantage and Commercial Products.All Blue Cross Blue Shield - Rhode Island updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-01-10Monitoring Devices and Supplies — Coverage CriteriaCoverage guidelines for home glucose monitors, non-implantable continuous glucose monitors (CGMs), and implantable CGMs for BCBSRI members, specifying Medicare Advantage and Commercial product rules.All Blue Cross Blue Shield - Rhode Island updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-01-05Acute Hepatitis Panel (coverage criteria)This policy governs medical necessity and coverage for acute hepatitis panel testing (CPT 80074) for BCBSRI Medicare Advantage and Commercial products, including indications, limitations, and coding requirements for providers ordering the test.All Blue Cross Blue Shield - Rhode Island updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-01-05Proprietary Laboratory Analyses (PLA) and Multianalyte Assays with Algorithmic Analyses (MAAA)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.All Blue Cross Blue Shield - Rhode Island updates
1–25 of 361
1 / 15
Tool Description
Search Blue Cross Blue Shield - Rhode Island coverage criteria and medical necessity requirements across 21,000+ policies from 170+ payers.
Search a drug (“Wegovy”), a procedure (“knee replacement”), or a policy name, then filter by payer, specialty, policy type, or effective year. Or start from the largest publishers: UnitedHealthcare coverage criteria and Cigna coverage criteria.
Each result links the full policy page, which lists the clinical requirements, covered codes, and effective dates from the source document.
Pair a criteria search with the prior authorization lookup for approval requirements, the timely filing lookup for claim deadlines, the live policy updates feed for the newest payer publications, and payer profiles for contacts and coverage context.
FAQ
Coverage criteria are the specific clinical requirements a payer sets for covering a drug, procedure, or service: diagnoses, symptom duration, prior treatments tried, age limits, and documentation. They are published inside medical policies and clinical criteria documents, and a claim or authorization that does not meet them is denied as not medically necessary.
Coverage Criteria by Payer
Go deeper
Explore OpenPayer Data
Coverage policies are updated every day. Follow payer coverage policy updates in the live policy feed, or browse all CPT, HCPCS and DRG billing codes.
Toolbox
More OpenPayer Tools
- Billing Code LookupSearch CPT, HCPCS, J-codes, DRG, and dental codes by number or procedure name.
- Billing Code Reimbursement RatesBuild a reimbursement rate report across any mix of billing codes and states, comparing commercial payers against Medicare.
- Payer Comparison DashboardPick 2-5 payers to compare market share, premium, and membership by region, all at once.
- Facility Comparison DashboardPick 2-6 hospital facility types (or add a specific hospital) to compare facility count, revenue, net income, and Medicare/Medicaid payer mix by region, all at once.
- Healthcare Provider & Facility LookupFind hospitals and healthcare facilities by name, taxonomy, facility type, ownership, or state.
- Health Insurance Payer LookupSearch national health insurance payers and health plans by name and state presence.
- Provider Taxonomy Code LookupSearch NUCC taxonomy codes by code, specialty, grouping, or classification.
- CPT Modifier LookupSearch CPT modifiers by code or name — descriptions, when to use them, and payer policy context.
- Prior Authorization LookupSearch payer prior authorization policies by drug, procedure, or policy name.
- Timely Filing LookupFind payer timely filing policies: claim deadlines, corrected claim windows, and appeal timeframes.
- Payer Contact DirectoryClaims, prior authorization, provider services, and appeals contacts for health insurance payers.
Published by
Trek Health powers OpenPayer with a leading commercial payer intelligence platform, seamlessly converting fragmented payer data into actionable insights for provider organizations.