Request preauthorization / Notification of Admission

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. Behavioral health inpatient and intermediate levels of care require a notification of admission/discharge. Failure to provide notification may result in your financial liability for all or part of the cost of services if the services are determined experimental, or investigatory.

Below is a list of some of the most common non-behavioral health services requiring preauthorization or notification of admission.

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

Medicare Advantage Plans and Commercial Products 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

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.

If you have a patient who is in need of Urgent BH care, please click here for our Urgent Access Providers.

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.