Pharmacy Post Claim Review Medications
The MPS list for both Commercial and Medicare plans within the Payment Policy Pharmacy – Post Claim Review Medications has been updated with the effective date of October 1, 2026. For additional details related to this policy, please click here.
Preventive Services for Commercial Members Policy
2026 Preventive Services for Medicare Advantage Plans
CPT code 87494 one multiplex (STI) sexually transmitted infection testing for both gonorrhea and chlamydia combination test has been added to both the Commercial and Medicare Advantage Preventive Policy as a covered preventive benefit effective January 1, 2026. For additional details related to these policies, please click the policy to review.
Preventive Services for Commercial Members Policy
Preventive Services for Medicare Advantage Plans
Fee-based Primary Care Network Providers Services formerly known as Physician Concierge Services
This policy was renamed to: Fee-based Primary Care Network Providers Services
(Formerly known as: Physician Concierge Services)
BCBSRI remains committed to improving the health of our members by providing access to high quality, cost-effective, equitable healthcare. As part of this commitment, BCBSRI reviews its fee schedules on an annual basis and makes updates as needed.
On September 21, 2026, the Rhode Island Office of the Health Insurance Commissioner (“OHIC”) issued Bulletin 2026-03, Health Insurer Requirements for Fee-Based Primary Care Network Providers (the “Bulletin”). The Bulletin requires insurers to identify fee-based primary care network providers, and to prioritize network PCPs that do not participate in fee-based practice models in required primary care investments. The Bulletin defines fee-based primary care network providers as PCPs that require beneficiaries to pay a membership, subscription, or other fee as a condition of obtaining or maintaining access to the provider.
This Payment Policy details updates to fee-based PCP attribution and participation in BCBSRI’s Provider Incentive Quality Program (PQIP), infrastructure payments, and other LAN Category II – IV APM models including but not limited to PCP Capitation, and Shared Savings/Global Capitation agreements.
For additional details related to this policy, please click here.
Maternity - Obstetrical Services
This is a new policy created with an effective date of January 1, 2027.
OB services will no longer be bundled per AMA/CPT. Providers will now bill for their own services they perform by using Evaluation and Management codes, delivery codes, etc. The AMA/CPT issued new OB codes effective January 1, 2027. The current bundled OB codes will be deleted on December 31, 2026.
For additional details related to this policy, please click here.
Please click on FAQ section within the policy for additional support.
High Risk Pregnancy Services
This policy will be archived and replaced with new Maternity Obstetrical Services Policy effective January 1, 2027.