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, PM&R (Physical Medicine & Rehab) +2 more·Physician
Effective date
Jan 1, 2026
We identified it
Jun 19, 2026
Summary
BCBSRI is expanding prior authorization requirements for physical and occupational therapy services for Medicare Advantage members only, effective January 1, 2026. Visits 1-14 per episode will require notification, while visits after the 14th will require prior authorization through eviCore.
Action Required
By December 2025: Register for mandatory eviCore training webinars at https://www.evicore.com/resources/healthplan/blue-cross-blue-shield/rhode-island to learn authorization processes. By January 1, 2026: Update billing workflows to submit notifications for PT/OT visits 1-14 and obtain prior authorization for visits 15+ per episode for BCBSRI Medicare Advantage members through eviCore portal. Review the Medical Policy 'Prior Authorization of Physical and Occupational Therapy Services' for specific affected codes. Claims without proper authorization will be denied.