CommercialPrior AuthMedium impact
Private Rooms 12.01.06
Excellus BlueCross BlueShield·Emergency Medicine, Critical Care, Infectious Disease +2 more·Miscellaneous
Effective date
Nov 20, 2025
We identified it
Jun 20, 2026
Summary
Excellus BlueCross BlueShield updated their private room policy, maintaining that private rooms are generally excluded from coverage except when medically necessary for specific conditions like contagious diseases, immunocompromised patients, radiation implants, severe burns, psychological conditions requiring isolation, or severe eclampsia. All private room requests require Health Plan Medical Director review and approval.
Action Required
By November 20, 2025: Billing team must ensure all private room charges for Excellus members include proper medical necessity documentation and obtain Health Plan Medical Director approval before admission. Update pre-authorization workflows to require clinical justification based on the six specific criteria (contagious disease, immunocompromised status, radiation implants, severe burns, psychological conditions, or severe eclampsia). Private room charges without prior approval will likely be denied.