CommercialPrior AuthHigh impact
BCBSMA initiating a new utilization management process
Blue Cross Blue Shield of Rhode Island·MA · Endocrinology, Orthopedics, Neurosurgery·Physician / Facility
Effective date
Jan 1, 2022
We identified it
Jun 19, 2026
Summary
BCBSMA is implementing new prior authorization requirements effective January 1, 2022, for Commercial EPO/PPO and Medicare Advantage members for continuous glucose monitors, spine surgeries, and other specified services. This aligns EPO/PPO products with existing HMO/POS requirements and extends coverage to Medicare Advantage members.
Action Required
By January 1, 2022: Billing team must implement prior authorization requirements for BCBSMA Commercial EPO/PPO and Medicare Advantage members. Update billing system to flag continuous glucose monitors (A9277, K0553, S1036) and all spine surgeries for prior auth verification. Train staff to call pre-authorization number on member cards before scheduling these services. Note that CGM authorizations are required annually. Claims will be denied without proper prior authorization.