CommercialCoverageHigh impact
Update to Level of Care Criteria Review
Blue Cross Blue Shield of Rhode Island·RI · General Surgery, Orthopedics, Neurosurgery +4 more·Facility
Effective date
Jul 1, 2021
We identified it
Jun 19, 2026
Summary
BCBSRI updated their level of care criteria using new InterQual guidelines, reclassifying many procedures from inpatient to observation or outpatient settings. Numerous surgical procedures including hernia repairs, mastectomies, spinal surgeries, and facial reconstructions will now require outpatient treatment unless complications warrant inpatient care.
Action Required
By July 1, 2021: Billing and utilization review teams must update pre-authorization protocols to reflect new outpatient requirements for hernia repairs, mastectomies, single-level spinal surgeries, facial reconstructions, and other listed procedures. Update case management workflows to justify inpatient level of care based on complications rather than procedure type. Train staff on new observation vs. inpatient criteria for GI bleeding, non-traumatic bleeding, and anemia cases. Claims may be denied or downgraded if appropriate level of care documentation is not provided.