Medicare AdvantagePrior AuthHigh impact
Physical and occupational therapy codes requiring PA for Medicare members effective 1/1/26
Blue Cross Blue Shield of Rhode Island·RI · Physical Therapy, Occupational Therapy·Physician
Effective date
Jan 1, 2026
We identified it
Jun 19, 2026
Summary
Starting January 1, 2026, BCBSRI Medicare Advantage members will require notification for physical and occupational therapy visits 1-14 per episode, and prior authorization through eviCore for visits after the 14th visit. Authorization requests for Prospect members continue through Prospect via fax.
Action Required
Before January 1, 2026: Billing team must update workflow to obtain notifications for PT/OT visits 1-14 and prior authorizations through eviCore for visits 15+ for BCBSRI Medicare Advantage members only. Continue using Prospect fax process for Prospect members. Register for eviCore training webinars in December (dates: 12/3, 12/11, 12/19, 12/29). Set up eviCore portal access and update billing system to track visit counts per episode of care. Claims without proper authorization after visit 14 will be denied.