Medicare AdvantageCoverageHigh impact
BlueCHiP for Medicare national and local coverage determinations policy
Blue Cross Blue Shield of Rhode Island·RI·Provider Update
Effective date
May 1, 2025
We identified it
Jun 19, 2026
Summary
BCBSRI BlueCHiP for Medicare will now follow CMS national and local coverage determinations (NCDs/LCDs) instead of commercial policy guidelines. Many existing BCBSRI policies now apply only to commercial products, requiring separate reference to Medicare NCD/LCD policies for BlueCHiP Medicare coverage decisions.
Action Required
By May 1, 2025: Billing team must stop using commercial BCBSRI policies for BlueCHiP Medicare claims. Begin referencing CMS NCDs and LCDs for coverage determinations instead of standard BCBSRI policies. Update prior authorization and coverage verification processes to check Medicare-specific guidelines rather than commercial policies. Review all pending BlueCHiP Medicare claims to ensure compliance with CMS guidelines rather than commercial coverage rules.