Traditional MedicarePrior AuthMedium impact
InterQual Changes in MHK
Blue Cross Blue Shield of Rhode Island·RI·Physician / Facility
Effective date
Apr 2, 2021
We identified it
Jun 19, 2026
Summary
BCBSRI updated their InterQual prior authorization criteria effective April 2, 2021 to ensure compliance with CMS National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs). When using InterQual for Medicare members in Rhode Island, providers must now select specific criteria hierarchies: NCDs when available, National Government Services for procedures, or Noridian for DME only.
Action Required
Authorization staff must update InterQual selection process for Medicare members: First select 'National Coverage Determination (NCD)' when available (takes priority), select 'National Government Services' for procedures, or select 'Noridian' for DME only. Train staff on the new hierarchy questions in InterQual system to ensure proper prior authorization approvals.