Preventative Services for Commercial Members policy
- This policy was updated to meet HRSA guidelines effective January 1, 2026.
Screening and Counseling for Intimate Partner and Domestic Violence
- Updated policy’s terminology from “intimate partner” to “interpersonal and domestic violence.”
Breast Cancer Screening for Women
- Updated policy to include new requirements to cover follow-up imaging (including mammography, ultrasound, and MRI) needed to complete the screening for malignancies.
- Procedure codes must be submitted with the screening diagnosis ICD-10; Z-codes to process as preventive services. (See grid for codes)
Patient Navigation Services for Breast and Cervical Screening (Not to be confused with CLINICAL Navigation Services) - PATIENT Navigation Services are provided by NON-clinical staff, such as a secretary/administrator’s assistant.
- Service examples may include scheduling follow up tests, helping patients overcome barriers such as transportation, language, or insurance concerns.
- BCBSRI has added Code G0023. This code description is: “Patient navigation services provided to women with abnormal breast and/ or cervical screening results, to ensure follow-up diagnostic services.”
- Code G0023 is currently on our NSR list indicating the services are “covered,” however not separately reimbursed.
For additional details related to this policy, please click here.
Preventive Services for Medicare Advantage Plans
Medicare NCD 210.4.1 indicated ICD-10 Code Z72.0 (tobacco use, current) to be added as a covered dx for Counseling to Prevent Tobacco Use to preventive policy for Medicare Advantage. For additional details related to this policy, please click here.
Lactation Consultations
This policy was updated to reflect that BCBSRI requires claims for lactation consultation services to be submitted on a single claim listing the mother as the patient. Any claims submitted under an infant (ages 0-12 months) will not be considered for reimbursement.
A maximum of one (1) unit for CPT Code 98960 (lactation consultation) per date of service will be considered for reimbursement.
For additional details related to this policy, please click here.
Sexually Transmitted Infections Testing
The policy has been updated to now instruct providers to charge for each STI test rendered.
When more than one is charged per date of service, BCBSRI will reimburse only the one “comprehensive” code.
The provider is required to bill for the applicable single STI CPT codes, as rendered. The comprehensive CPT code will be reimbursed as indicated above.
For additional details related to this policy, please click here.
Hearing Aid Coverage and Mandate
Effective January 1, 2026 the rate will increase from $1,500 to $1,750 per individual hearing aid and age restrictions will be removed.
Starting January 1, 2026, upon a plan’s renewal, BCBSRI commercial plans with hearing aid coverage eliminate the distinction in hearing aid benefits by age and raise the coverage for certain products.
For additional details related to this policy, please click here.
Newborn Metabolic, Endocrine and Hemoglobinopathy and the Newborn Hearing Loss Screening Programs Mandate
The newborn screening program mandate was amended on June 24, 2025. The following two updates have been made to this policy:
First, this year’s amendment adds the types of providers who can order the test.
The physician, nurse practitioner, physician assistant and/or midwife attending a newborn child shall cause said child to be subject to newborn screening tests for the conditions listed below.
We have matched our list to the RI Department of Health’s newborn screening blood tests list to match. The list of testing added/removed are as follows per the list from DOH site as of (7.28.2025).
Tests ADDED to policy:
6. Lysomal Storage Conditions
a. Glycogen Storage Disease Type II (Pompe)
b. Mucopolysaccharidosis Type I (MPS I)
7. Neuromuscular Disorders
a. Spinal Muscular Atrophy (SMA) (PA edit will be removed from this test)
8. Others
g. X-linked Adrenoleukodystrophy (X-ALD)
BCBSRI moved and added heading to mirror DOH’s list
“Endocrine Disorder”
Congenital Adrenal Hyperplasia
Congenital Hypothyroidism
For additional details related to this policy, please click here
Coding and Payment Guidelines / Modifiers
Effective November 1, 2025, modifier QL was added for Ambulance billing (ground and air).
QL modifier billable with HCPCS codes A0428-A0429 & A0430-A0431
For additional details related to this policy, please click here.
Behavioral Health Outpatient Professional Services
This policy was updated to indicate LCDP’s are not credentialled for Medicare plans
For additional details related to this policy, please click here.
Preventive Services for Commercial Members
This policy was updated to add CPT code 58661 “tubal ligation” with dx code Z30.19 to be covered as preventive service effective January 1, 2025.
This policy was updated to update CPT code A4288 for valve for breast pump, replacement – we updated the limit to 2 units per 12 months.
For additional details related to this policy, please click here.
Radiopharmaceuticals
This policy was updated to cover CPT code A9616 for all lines of business and reimbursable for professional and facility.
For additional details related to this policy, please click here.
COVID-19 Monoclonal Antibody Treatment and Antiviral IV Medications
The following codes have been added to the policy with an effective date of January 24, 2025
- M0237 Intrav inf, tocilizumab-anoh, first dose
- M0238 Intrav inf, tocilizumab-anoh, second dose
- Q0237 Inj, tocilizumab-anoh, hospital
The following codes have been added to the policy with an effective date of October 1, 2025
- M0235 Intrav inf, monoclon antibody, fir dose
- M0236 Intrav inf, monoclon antibody, sec dose
- Q0235 Inj, monoclon antibody, 1 mg
- Q5156 Inj, tocilizumab-anoh, 1 mg
For additional details related to this policy, please click here.
Non-Reimbursable Health Service Code Policy
The following codes are considered NSR effective October 1, 2025:
*Only payable to DME Providers
For additional details related to this policy, please click here.