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 partners with Beacon Health Options, an independent, managed behavioral health vendor, to ensure members receive the right behavioral health services at the right time.

For commercial and Medicare Advantage products, BCBSRI requires providers/facilities to complete a notification of admission and a notification of discharge for the following services when rendered by an in-network provider or facility.

Admitting facilities and providers will utilize the ProviderConnect portal for notification of admission and discharge for all of the following levels of care:

  • 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)*

*In-network ABA and TMS services require the notice of admission to be submitted telephonically or via fax. Please find the fax form here or contact Beacon Health Options at 1-800-274-2958 to provide the notice.
 

In-network providers and facilities may utilize ProviderConnect, an electronic portal, 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.

To obtain access to the portal, complete the Online Service Account Request Form and fax it to 1-866-698-6032. Call Beacon Health Options at 1-800-274-2958 if you have questions.

For additional training and FAQs about behavioral health authorizations, visit Beacon Health Options.

For commercial and Medicare Advantage, when the following services are performed by an out-of-network provider or facility, preauthorization is recommended:

  • 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
  • Applied Behavior Analysis (ABA) services**
  • Transcranial Magnetic Stimulation (TMS)**

**Out-of-network ABA and TMS services require preauthorization to be requested via fax, please find the fax form here.

Please contact Beacon Health Options at 1-800-274-2958 to request preauthorization for all other services.

Beacon Health Options is an independent company, contracted by Blue Cross & Blue Shield of Rhode Island to provide behavioral health management services.

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