Frequently Asked Questions


For members of other Blue Plans, you may verify membership and coverage by phone or by submitting electronic inquiries.

  • Phone: Call the telephone number on the back of the member's ID card. If that information is not available, call BlueCard Eligibility at 1 (800) 676-BLUE (2583). You will be prompted for the member's alpha prefix and connected to the appropriate Blue Plan.
  • Electronic inquiry: Submit a HIPAA 270 transaction (eligibility) to BCBSRI. The majority of BlueCard electronic inquiries are answered within 48-72 hours (Monday through Friday during regular office hours).
  • Provider Website: Utilize the Eligibility Search by Member ID in the Patient Eligibility section of the Provider Website.

To determine the member's participation status, check the suitcase logo.

  • A blank suitcase logo on a member's ID card indicates that the patient has traditional, POS or HMO benefits delivered through the BlueCard program.
  • A PPO in the suitcase logo indicates the patient has PPO benefits.

Blue Plan is primary
Submit claims to your local Blue Plan—BCBSRI. Do not bill Medicare directly for any services rendered to a Medicare Advantage member.

Medicare is primary
When Medicare is the primary payer for an out-of-area Blue Plan member (e.g., Medigap plans), follow these procedures:

  1. Submit claims to your local Medicare contractor first. Do not file with Medicare and the supplemental insurer simultaneously. Be sure to include the:
    • complete Health Insurance Claim Number (HICN),
    • patient's complete ID number,
    • patient's name as it appears on the card.
  2. After you receive an Explanation of Medical Benefits (EOMB) or Medicare Remittance Notice (MRN), determine if the claim was automatically crossed over to the supplemental insurer:
    • Crossed over: If the indicator on the EOMB or MRN shows that the claim was crossed over, Medicare has forwarded the claim on your behalf to the appropriate Blue Plan and the claim is in process. You do not need to file for the Medicare supplemental benefits. The Medicare supplemental insurer will automatically pay you, if you accepted Medicare assignment. Otherwise, the member will be paid and you will need to bill the member.
    • Not crossed over: If the EOMB or MRN does not indicate the claim was crossed-over, file the claim as you do today to BCBSRI. BCBSRI or the member's Blue Plan will pay you the Medicare supplemental benefits. If you did not accept Medicare assignment, the member will be paid and you will need to bill the member.

Coordination of Benefits (COB) refers to how we ensure members receive benefits while preventing double payment for services when a member has coverage from two or more payers. The member's contract language explains which payer has primary responsibility for payment. Please follow the procedures below for submitting COB claims.

  • Member has coverage with two out-of-area Blue Plans
    • Send the claim to BCBSRI with the primary member ID first.
    • After you receive the Explanation of Benefits (EOB), send the information with a new bill to BCBSRI for secondary payment. The claim will not automatically cross-over.
  • Another carrier is the primary payer and a Blue Plan is secondary
    • Bill the other carrier first.
    • Send the EOB from the other carrier with the claim to BCBSRI for secondary payment. The claim will not automatically cross-over.

If you are an indirect, support or remote provider for members from multiple Blue Plans, follow these claim-filing procedures:

  • If you have a contract with the member's Blue Plan, file with that Plan.
  • If you normally send claims to the direct provider of care, follow normal procedures.
  • If you do not normally send claims to the direct provider of care and you do not have a contract with the member's Blue Plan, file with your local Blue Plan—BCBSRI.
  • If you are a health care provider that offers products, materials, informational reports and remote analyses or services, and are not present in the same physical location as a patient, you are considered an indirect, support, or remote provider. Examples include, but are limited to:
    • prosthesis manufacturers,
    • durable medical equipment suppliers,
    • independent or chain laboratories, or
    • telemedicine providers

When members of Blue Plans arrive in your office or facility, be sure to ask for their current member identification (ID) card. The card identifies BlueCard members with an alpha prefix. The ID cards may also have:

  • A blank suitcase logo
  • A PPO in a suitcase logo
  • No suitcase logo

There are two types of alpha prefixes: plan-specific and account-specific. Plan-specific alpha prefixes are assigned to every Blue Plan and start with X, Y, Z, or Q. The first two positions indicate the Blue Plan to which the member belongs. The third position identifies the product in which the member is enrolled.

  • First character X, Y, Z or Q
  • Second character A-Z
  • Third character A-Z

Account-specific prefixes are assigned to centrally processed national accounts. National accounts are employer groups that have offices or branches in more than one area, but offer uniform benefits coverage to all of their employees. Account-specific alpha prefixes:

  • Start with letters other than X, Y, Z, or Q.
  • Typically relate to the name of the group.
  • Use all three positions to identify the national account.
  1. Once BCBSRI receives a claim, we will price the claim based on your contract with us (participating or preferred) and electronically route the claim to the member's Blue Plan.
  2. The member's Blue Plan adjudicates the claim and approves payment based on the member's benefits.
  3. BCBSRI will reimburse you accordingly and provide information on your payment voucher.

Submit claims directly to the member's Blue Plan instead of BCBSRI in the following situations:

  • You contract with the member's Blue Plan.
  • The member's ID card does not include an alpha prefix.
  • The benefits are excluded from the BlueCard Program (e.g., dental and prescription medications).
  • The member belongs to the Federal Employee Program (FEP) - please follow your FEP guidelines. When in doubt, please submit the claim to us electronically or send the paper claim to us at:

    Blue Cross & Blue Shield of Rhode Island
    500 Exchange Street
    Providence, RI 02903

    Please note: Occasionally you may be asked to submit BlueCard claims directly to the member's Blue Plan. For instance, there may be a temporary processing issue at BCBSRI or the member's Blue Plan or both that prevents completion of claims through the BlueCard Program.

The claim submission process for international Blue Plan members is the same as for domestic Blue Plan members. You should submit the claim directly to BCBSRI.

Submit BlueCard claims electronically with your other BCBSRI claims or send paper claims to:

Blue Cross & Blue Shield of Rhode Island
500 Exchange Street
Providence, RI 02903

Be sure to include the member's complete ID number when you submit the claim. The complete ID number includes the three-character alpha prefix. Incorrect or missing alpha prefixes and ID numbers delay claims processing. Do not send duplicate claims.

You should remind patients from other Blue Plans that they are responsible for obtaining pre-certification/pre-authorization for their services from their Blue Plan. Please note: Other Blue Plan's pre-authorization lists may differ from BCBSRI's.

You may also choose to contact the member's Blue Plan on behalf of the member by phone.

Phone-Call the telephone number on the back of the member's ID card or BlueCard Eligibility at 1 (800) 676-BLUE (2583). You will be prompted for the member's alpha prefix and connected to the appropriate Blue Plan. Ask to be transferred to the utilization review area.

If the member's ID card has an alpha prefix (with or without a suitcase logo), send it to your local Blue Plan—BCBSRI. It will be paid at the member's Blue Plan's allowable. You will receive any reimbursement from your local plan.

The three-character* alpha prefix is the key element used to identify members and route out-of-area claims. The alpha prefix identifies the Blue Plan or national account to which the member belongs. It is critical for confirming a patient's membership and coverage. The remaining portion of the member's ID consists of seven to 14 alpha and/or numeric characters. We suggest you make copies of the front and back of the member's ID card and share this information with your billing staff.

It's important that you do not add or delete any alpha/numeric characters in the member's ID number.

*You may see member ID cards with a four-character alpha prefix (e.g., members of HMSA Blue Cross Blue Shield of Hawaii).

A national program that offers members traveling or living outside of their Blue Plan's area the Preferred Provider Organization (PPO) level of benefits when they obtain services from a physician or hospital designated as a BlueCard PPO provider. To find out if you're a BlueCard PPO provider, visit

Similar to BlueCard traditional and BlueCard PPO, BlueCard Managed Care/POS (point-of-service) program is for members who reside outside their Blue Plan's service area. However, unlike other BlueCard Programs, BlueCard Managed Care/POS members are enrolled in HMO networks and primary care physician (PCP) panels. Therefore, you should treat these members as you treat any other BCBSRI Managed Care/POS member, applying the same referral practices and network protocols.

Dental services and prescription medication benefits are excluded from the BlueCard Program. In addition, claims for Federal Employee Program (FEP) are exempt from the BlueCard Program.

The BlueCard Program applies to all inpatient, outpatient and professional claims. This includes traditional, Preferred Provider Organization (PPO), Point-of-Service (POS) and Health Maintenance Organization (HMO) products.

BlueCard is a national program that enables members of one Blue Cross and/or Blue Shield Plan (Blue Plan) to obtain health care services while traveling or living in another Blue Plan's service area. The program links participating health care providers with the independent Blue Plans across the country and in more than 200 countries and territories worldwide through a single electronic network for claims processing and reimbursement.

The program allows you to conveniently submit claims for patients from other Blue Plans, domestic and international, to your local Blue Plan — BCBSRI.

BCBSRI is your contact for claims payment, problem resolution and adjustments.

Radiology / Management Program

No. You must follow the rules of the member’s Home Plan.

Example 1 - A BCBSRI member is seen in Idaho: Member DOES need authorization. 

Example 2 - A BCBS of Idaho member is seen in RI: Follow rules for the Blue Cross plan in Idaho. This authorization process is for BCBSRI members only.

The claim will deny.

Example: A facility or provider office initiates an authorization on March 1, 2009.  The patient has the test done on March 1st, but eviCore does not approve the test until March 2, 2009.  The approval date range is from March 2 – June 2, 2009 (90 days).  Because the date of service is not within the approval range the claim will deny.  It is strongly recommended that patients do not have tests done until eviCore has issued a determination. 

1 year/365 calendar days for commercial and BlueCHiP for RIte Care and 2 years/730 calendar days for BlueCHiP for Medicare. Keep in mind that timely filing rules still apply.

eviCore has the Tax ID information of the facilities in the BCBSRI network.

A medically urgent condition is one in which the treating physician feels the patient’s clinical condition requires advanced imaging that day. Urgent (same day) requests are accepted by phone only at (888) 233-8158.

eviCore does not currently have intake staff available on the weekends, other than what is required by law. eviCore suggests utilizing the Web portal for prior authorization submission and case status lookup on the weekends.

A provider can obtain unmanaged status for Classic members by contacting the Physician and Provider Service Center.

The appeals process timeframe is different for different products. They are as follows:

BlueCHiP for Medicare: There is one appeal level and if it is upheld the case is sent to Maximus for independent review. Standard timeframe is 30 days and a Fast Review is 72 hours.

Commercial and BlueCHiP for RIteCare: Standard review is 15 calendar days. Expedited requests are processed within 2 business days.

eviCore advises the provider to give them as much information as they have available to them. The authorization process may have to pend until all of the documentation required is obtained.

Typically, the office staff provides the clinical information. It is up to each office to determine the best work flow for this process.

eviCore will obtain this information from BCBSRI.

The ordering physician or facility should assign the appropriate CPT code. eviCore can assign the CPT code if the ordering physician does not have it available.

Yes. However, BCBSRI is not paying claims based on a facility match. eviCore requires facility information for tracking purposes, to ensure the facility is participating with BCBSRI, and to notify the facility of approvals or denials.

Members can go to any BCBSRI participating radiology provider. eviCore has a list of participating providers and will offer suggestions based on geographic location if the physician does not have a particular facility in mind. 

The ordering physician will have to call eviCore to update the authorization to reflect the new date.   

This program applies to all BCBSRI products except Plan 65, Federal Employees Program (FEP), Classic Unmanaged, and New England Health Plan members.

Yes. An authorization is only valid for 90 days, so the authorization will need to be obtained closer to the actual service date.

Members should be directed to call the BCBSRI Customer Service Department regarding denials. The number for members to contact is located on the back of their BCBSRI member identification card.

The physician or the office staff can initiate an appeal for all patients except BlueCHiP for Medicare. Appeals from BlueCHiP for Medicare patients must be initiated from the member, but providers may assist the member with the process. eviCore must follow CMS guidelines regarding high-tech radiology denials issued to our Medicare Advantage (MA) members. When a denial is issued, eviCore mails MA members their appeal information with a 1696 form that they must sign. If the member presents to your office and does not have the form that was mailed to he/she, you may contact eviCore to obtain this 1696 appeal form on behalf of the member. eviCore can fax this form to you and you can assist the member in completing this form.  For your convenience, please see the 1696 appeal formYou can file an appeal by fax to (888) 693-3209.

No, because they will not have all of the required clinical information needed. eviCore will not take information from a patient.

eviCore’ PRI software now recognizes ordering physician specialty, demographic information, requested study, and diagnosis immediately. It is possible for the requesting provider to receive an approval within a very short period of time.

No, BCBSRI is not reimbursing provider offices.

Instantaneously. The Web site functions in real time.

Authorizations are valid for 90 days.

No, the first point of contact is not clinical. eviCore uses guidelines to determine if an authorization can be granted at the first point of contact. If a decision cannot be made at this point, the caller is transferred to a nurse.

No, any routine maintenance is done on weekends.

BCBSRI will be sending eviCore a weekly eligibility file. eviCore and BCBSRI have also arranged to ensure eviCore can obtain current eligibility information telephonically and through the BCBSRI portal.

Yes, the financial liability falls on the radiology facility if a test is rendered without authorization.  However, if the radiologist performs the read only (Modifier 26), the claim will pay for BCBSRI members regardless of authorization.

No, it would have to meet the guidelines for an urgent request. Just because the service was rendered at an urgent care center does not ensure the claim will process as an urgent or emergent request. It must meet those guidelines.

Yes, the authorization process applies to machines in provider offices.

The authorization will get faxed to the fax number that the requesting physician provided to eviCore.

No, unless he or she signs a waiver of liability before the test is performed. If authorization and a waiver are not obtained, the liability will fall on the radiologist who rendered the service and the claim will deny provider liability.

If an authorization is denied or has not been obtained, the provider office can create a waiver of liability that specifically states that the authorization has not been obtained or has been denied. If the member still wants to have the test done, the member can sign the waiver stating that he or she knows he or she will be billed for the service. A BCBSRI member who receives non-emergent studies out of area without an authorization may also be held liable.

No. eviCore will suggest a participating facility if the provider office does not know where to send the patient, but the provider office or member can choose the facility they want the patient to utilize.

eviCore will fax the office requesting additional information.

eviCore suggests sending the information together as it might slow the process down if they have to “stop the clock” to wait for the clinical information. 

eviCore advises to go ahead and perform the appropriate test and then notify them within 48 hours. eviCore may request clinical documentation to support the request and will update the authorization accordingly.

eviCore is open until 9 p.m. EST. The authorization is faxed to both the ordering physician’s office as well as the facility rendering the service so the patient can check with the facility to see if the authorization has been obtained. Also, most facilities have access to the eviCore Web portal so they can check the status of a request.

Denial rates vary across the country, and BCBSRI will not be able to determine its denial rate until the system is up and running. However, BCBSRI estimates an 8 percent denial rate.

eviCore has a dedicated phone number for BCBSRI requests attached to multiple phone lines. eviCore has a service agreement with BCBSRI to answer a call within 30 seconds.

Faxed requests for tests that meet medical necessity upon the initial submission of all necessary clinical information may be turned around in as quickly as 4 hours.

Authorizations can be initiated via the Web 24 hours a day, 7 days a week.

Multiple users can share the same log-in and be logged in at the same time. However, it is advisable that each individual requiring access to the information provided via the eviCore Web portal have his or her own log-in.

We have sent out letters to our members and there will be an article in the winter edition of our member magazine, Choices. A handout to be given to members by physicians will be available on the provider section of

There are questions with check-off boxes for you to check when completing the prior authorization online. There are also open-ended sections available to enter clinical information. In addition, medical records can be submitted electronically via the Web.

eviCore has one fax number for authorizations and one fax number for appeals. Faxes are automatically scanned into the eviCore authorization system and enter a queue for processing. eviCore utilizes a digital fax server. Volume is not an issue with this system. Authorization fax number is (888) 693-3210. Appeal fax number is (888) 693-3209.

The Doctor of the Day is the eviCore Medical Director assigned to have peer-to-peer discussions with physicians regarding the necessity of an imaging study. To speak with a Medical Director please call (888) 693-3211 and press option 3. If the Doctor of the Day is not the same specialty as the ordering physician, eviCore can accommodate the need to have the ordering physician speak with someone of his or her like specialty. Physicians may also request to consult with a eviCore Medical Director regarding general questions about clinical guidelines or appropriateness of a study at any time during normal business hours.

Blue Cross & Blue Shield of Rhode Island (BCBSRI) currently has a profile process in which providers are evaluated compared to their peers on ordering patterns. The information obtained from eviCore will assist BCBSRI in compiling this information. This additional information will be used when meeting with physicians to review their ordering patterns.

8:00 a.m. to 9:00 p.m. EST.

Urgent care providers will be held responsible for obtaining prior authorization. Although the eviCore call centers are not available on the weekends, the Web site is available 24 hours a day, 7 days a week. In the event a member presents with an urgent condition, a provider can attempt to obtain authorization on the Web. If approval is not granted over the Web, the provider may leave a  message on the eviCore voice mail and someone will contact the provider on the following business day. 

eviCore asks that these modifications occur within 48 hours. However, at the very least, any modification should occur prior to submitting a claim. You can make changes to an approved test by contacting the eviCore Provider Assistance Desk (PAD) by email at Please see the Authorization Update Document for more details.

eviCore does not conduct prior authorization for workers’ compensation patients.

Authorization for multiple studies is handled as one authorization. Each specific study needs to be approved, but all studies are included on one authorization. Authorizations are effective for 90 days from the date the case is adjudicated by eviCore.

Yes. You are encouraged to ask the radiologist when scheduling the appointment if contrast is needed. eviCore approves at the highest contrast level. In the event the radiologist modifies the contrast level after the test has been authorized you do not need to contact eviCore for contrast changes.

Yes. Although tests rendered in an emergency room (ER) are excluded, those ordered in the ER as part of a member’s discharge are not excluded. The standard authorization procedures must be followed for these tests.

Facilities are aware of the authorization process and will confirm whether authorization was granted prior to scheduling a test. If a test is conducted without authorization, the facility will be held financially responsible for the charges.

Approximately two-thirds of requests are approved within 15 minutes. The remaining requests are typically adjudicated within 24 hours provided that eviCore has received all necessary clinical information needed to make a determination. If additional clinical information is requested, it may take up to two business days from the date of the initial submission to handle a request for prior authorization.

You can contact eviCore by phone, fax and email. To speak with a representative to initiate an authorization or to speak with a eviCore Medical Director call (888) 233-8158. To correspond with a representative regarding modifications to an existing authorization please contact the Provider Assistance Desk (PAD) at To initiate an authorization through fax please send to (888) 693-3210.

General Questions

Claims should be submitted to:

Blue Cross & Blue Shield of Rhode Island
500 Exchange Street
Providence, Rhode Island 02903-2699


In the following instances, claims should not be submitted to Blue Cross & Blue Shield of Rhode Island (BCBSRI):

  1. When there is another medical insurance carrier that is primary over Blue Cross & Blue Shield of Rhode Island. These claims should be filed to the primary carrier.
  2. When the claims are workers' compensation claims that are not through Beacon Insurance Company (Beacon claims are filed with BCBSRI). These claims should be filed to the appropriate worker's compensation carrier.

Having key pieces of information available for our representatives will allow us to help you more efficiently.

Please have the following pieces of information available:

  • Your NPI number
  • Patient information, including name and member identification number
  • Claim information, including date of service, procedure code, charge, and claim number
  • Settlement number, if applicable
  • Settlement date, if applicable
  • Claims issues/adjustment requests
  • Policy questions
  • Product/benefit information
  • Payment Issues
  • Provider demographics/practice information

Prior authorization for the high end imaging services (including CT scans, PET scans, MRI, MRa, and Cardiac Imaging), can be by contacting our radiology management vendor, MedSolutions, Inc. MedSolutions accepts authorizations requests by phone, fax, and online. Please download the Three Ways to Obtain Radiology Prior authorization document, and visit the Radiology FaQs section for more details.

Prior authorization for aftercare and acute care coordination services can be obtained by calling our Health Management and Integration department at (401) 272-5670. If you are calling from out-of-state, please call one of our toll free numbers: 1-800-635-2477 or 1-800-727-2300. authorizations for these services can also be obtained by submitting a Preauthorization Request on our Web site.

Information to have available for our representatives:

The patient's name, identification number, what the procedure is, date of the procedure, and location (hospital or other).

Please refer to the July 2002 Policy Update for detailed information. For a copy, contact the Provider Service Center.

Please complete a Practitioner Change form and a W-9 form; these are available on our Web site. If you prefer to speak with a representative, please call the Physician and Provider Service Department at (401) 274-4848 or 1-800-230-9050.

The provider should complete a Provider application Request form via our Web site. The provider can also request an application by calling our Physician and Provider Service Department representatives at (401) 274-4848 or 1-800-230-9050.

The primary care provider (PCP) coordinates the patient's care by referring the patient to specialists when needed. All BCBSRI PCPs are required to use our web-based referral management tool to generate referrals. Please click here to see our list of products that require a referral.

The new identification cards will show the member's copayments for specific services. The product name also appears on the card.

When reading your settlement, use the reimbursement column to calculate payments. If you have any questions regarding your settlement, you may call the Physician and Provider Service Department at (401) 274-4848 or 1-800-230-9050.

We recommend preauthorization for all inpatient procedures. We also review services that could be considered cosmetic.

Please call Provider Services at (401) 274-4848 or 1-800-230-9050.

BlueLine is an automated system that is available 24 hours a day, seven days a week. BlueLine provides quick and easy access to membership, eligibility, and benefit information, as well as detailed claims status.

To access BlueLine:

  1. Call (401) 272-1590 or 1-800-327-6712
  2. Follow the instructions for entering your provider number
  3. Press one (1) for benefits or two (2) for claims
  4. Enter the member's identification number

Press 0 at any time to reach a representative.

In-state: (401) 274-4848

Outside of Rhode Island: 1-800-230-9050

Call center hours of operation:

Monday through Friday, 8:00 a.m. to 4:30 p.m.