CommercialPrior AuthMedium impact
Revisions to the Change Healthcare InterQual criteria
Blue Cross Blue Shield of Rhode Island·RI · Oncology, OB-GYN, Urology +2 more·Physician / Facility
Effective date
Nov 1, 2023
We identified it
Jun 19, 2026
Summary
BCBSRI has revised the Change Healthcare InterQual criteria for genetic testing related to hereditary cancers, including BRCA1/BRCA2 testing, hereditary prostate cancer, Li-Fraumeni syndrome, and pharmacogenomic testing for breast cancer and NSCLC. These revisions will affect prior authorization and coverage decisions for genetic testing services.
Action Required
By November 1, 2023: Billing team and providers must review updated InterQual criteria for genetic testing claims including BRCA1/BRCA2, hereditary prostate cancer, Li-Fraumeni syndrome, multi-gene panels for hereditary breast and ovarian cancer, and pharmacogenomic testing. Update prior authorization requests to align with revised criteria. Claims not meeting updated InterQual standards may be denied.