Beginning on 2 de abril, 2021, you may notice a change to some of the InterQual content used during the prior authorization process.  In order to ensure that the criteria used in the tool is compliant with National Coverage Determination (NCD) and Local Coverage Determination (LCD) criteria as designed by CMS, we will be leveraging Change Healthcare’s Medicare compliant criteria.  Per BCBSRI medical policy, any time an NCD is available, the NCD should be followed to determine coverage.  When no NCD exists, LCD should be used. 

When services are rendered in Rhode Island, the following LCD criteria should be followed:

Durable Medical Equipment (DME) = Noridian

Procedures = National Government Service (NGS)

You will notice that when selecting criteria for a Medicare member, the first question in the criteria may look different than what you are used to.  

Since RI’s LCD is National Government Services, the expectation is that you would select ‘National Government Services’ in Question one.

If you see National Coverage Determination (NCD), which trumps the Local Coverage Determination (NCD).  The expectation is that you would select ‘National Coverage Determination (NCD)’ in this instance.

Since RI’s Local Coverage Determination is Noridian (for DME ONLY), the expectation is that you would select ‘Noridian’ in Question one.