Provider Remittance Advices
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Request preauthorization

Preauthorization allows us to review and determine the medical necessity of a service, drug, and/or the appropriateness of the setting. Preauthorization is required or recommended (based on the plan) for a number of services and drugs as noted in our policies.

In addition, we recommend preauthorization for all elective inpatient admissions, some procedures that may be considered cosmetic, and before services are performed outside the local participating provider network. Failure to obtain preauthorization may result in your financial liability for all or part of the cost of services if the services are determined not medically necessary, experimental, or investigatory.

Below is a list of some of the most common services requiring preauthorization or notification.

Non-radiologic services

The services below require preauthorization:

  • Inpatient acute medical facility admissions
  • Acute rehabilitation facility admissions
  • Services obtained outside the local participating provider network
  • Skilled nursing facility admissions

To obtain preauthorization, log in to your Provider portal account and use the online tool there.

If you have questions, please contact the Utilization Management Department:

(401) 272-5670
1-800-635-2477 (outside of Rhode Island only)
(401) 272-8885 (fax)

Radiology services

  1. First, determine if you need preauthorization for radiology services based on medical policy and benefits.
  2. If you need preauthorization, contact eviCore in one of three ways:

eviCore is a trademark of eviCore healthcare, LLC, an independent company that provides utilization review for select healthcare services on behalf of BCBSRI.
 

Behavioral health services

BCBSRI’s Behavioral Health team works diligently to ensure members receive the right behavioral health services at the right time.

Depending on a member’s product type and level of care being requested, BCBSRI requires providers/facilities to complete a notification of admission and a notification of discharge or medical necessity review for behavioral health services. See below for additional details.

Notification of Admission/Discharge:

The following levels of care, by product type, require admitting facilities and providers to provide notice of admission and discharge information to BCBSRI.

Commercial In-Network services:

  • Inpatient mental health and substance use disorder treatment
  • Inpatient withdrawal management (detoxification)
  • Crisis stabilization unit
  • Residential mental health and substance use disorder treatment
  • Partial hospitalization, mental health and substance use disorders
  • Intensive outpatient, mental health and substance use disorder
  • Child and family intensive treatment (CFIT)
  • Applied Behavior Analysis (ABA) services
  • Transcranial Magnetic Stimulation (TMS)

Commercial Out of Network Services:

  • Inpatient mental health and substance use disorder treatment
  • Inpatient withdrawal management (detoxification)
  • Applied Behavior Analysis (ABA) services

Medicare In and Out of Network Services:

  • Inpatient mental health and substance use disorder treatment
  • Inpatient withdrawal management (detoxification)
  • Partial hospitalization, mental health and substance use disorders
  • Intensive outpatient, mental health and substance use disorder
  • Transcranial Magnetic Stimulation (TMS)

In-network providers and facilities may utilize the MHK portal, BCBSRI’s electronic authorization tool, to provide the notice of admission and discharge. The notice is required within 48 hours of admission to the service and within 48 hours of the discharge in order to avoid claims issues.

If you are a provider unable to access the MHK portal, please complete this form and fax to 401-459-2503. BCBSRI’s BH staff will be in touch with you within 3 business days to provide your authorization number needed for claims processing.

To obtain access to bcbsri.com or if you need assistance with MHK, please contact our Provider Relations team at ProviderRelations@bcbsri.org.

Medical Necessity Review:

The following levels of care, by product type, require admitting facilities and providers to provide complete a medical necessity review for authorization:

Commercial Out of Network:

  • Crisis stabilization unit
  • Residential mental health and substance use disorder treatment
  • Partial hospitalization, mental health and substance use disorders
  • Intensive outpatient, mental health and substance use disorder
  • Child and family intensive treatment (CFIT)
  • Applied Behavior Analysis (ABA) services
  • Transcranial Magnetic Stimulation (TMS)

Federal Employee Plan (FEP):

  • Inpatient mental health and substance use disorder treatment
  • Inpatient withdrawal management (detoxification)
  • Residential mental health and substance use disorder treatment

If you are a provider unable to access the MHK portal to initiate the authorization process, please complete this form and fax to 401-459-2503 or contact BCBSRI at 800-274-2958 to obtain authorization.

For additional information regarding inpatient and intermediate levels of behavioral health services, please click here.

Authorizations for Laboratory Services

Only the ordering physician shall be involved in the authorization, appeal or other administrative processes related to prior authorization/medical necessity for laboratory services.

In no circumstance shall a physician/provider use a representative or a third party to obtain authorization on behalf of the ordering physician, to facilitate any portion of the authorization process or any subsequent appeal of a claim where the authorization process was not followed and/or a denial for clinical appropriateness was issued, including any element of the preparation of necessary documentation of clinical appropriateness. If a third party is found to be supporting any portion of the authorization process, BCBSRI will deem the action a violation of this policy and severe action will be taken up to and including termination from the BCBSRI provider network.

BlueCHiP for Medicare and Commercial Products

Laboratories and/or a third party vendors are not allowed are not allowed to obtain clinical authorization or participate in the authorization process on behalf of the ordering physician. Only the ordering physician shall be involved in the authorization, appeal or other administrative processes related to prior authorization/medical necessity.

In no circumstance shall a laboratory or a physician/provider use a representative of a laboratory or anyone with a relationship to a laboratory and/or a third party to obtain authorization on behalf of the ordering physician, to facilitate any portion of the authorization process or any subsequent appeal of a claim where the authorization process was not followed and/or a denial for clinical appropriateness was issued, including any element of the preparation of necessary documentation of clinical appropriateness. If a laboratory or a third party is found to be supporting any portion of the authorization process, BCBSRI will deem the action a violation of this policy and severe action will be taken up to and including termination from the BCBSRI provider network. If a laboratory provides a laboratory service that has not been authorized, the service will be denied as the financial liability of the participating laboratory and may not be billed to the member.”