CommercialPrior AuthHigh impact
UPDATE – Level of Care Criteria Review
Blue Cross Blue Shield of Rhode Island·RI · Gastroenterology, Pulmonology, General Surgery +4 more·Physician / Facility
Effective date
Jul 18, 2022
We identified it
Jun 19, 2026
Summary
BCBSRI updated their medical necessity review criteria using InterQual guidelines, effective July 18, 2022. The changes include new pediatric subsets and revised procedures that may now require review to determine if inpatient versus observation level of care is appropriate, particularly affecting GI, respiratory, surgical, and orthopedic procedures.
Action Required
By July 18, 2022: Clinical and billing teams must review all procedures listed in the InterQual updates, particularly bronchoscopy, appendectomy, laparoscopy, skin grafts, spinal procedures, tonsillectomy, and joint replacement procedures. Update prior authorization workflows to ensure proper level of care determination (inpatient vs observation) for procedures marked with asterisks. Contact Karen.Labbe@bcbsri.org for questions about specific procedures.