RI Payment Policy Update: 2026 Key Insurance Changes
APTA RI Payment Committee will continue to monitor and share policy updates.
For questions or to report payer issues, please contact the Payment Policy Committee.
1. BCBSRI – Medicare Advantage (BlueCHiP & D-SNP)
Prior Authorization Requirement – Effective January 1, 2026
Update:
BCBSRI Medicare Advantage plans (BlueCHiP for Medicare and D-SNP) are implementing prior authorization requirements for outpatient PT/OT services beginning 1/1/2026
Authorization is managed through eviCore healthcare
Key Details:
- Applies to new episodes of care
- Requires submission of clinical documentation to support medical necessity
- Ongoing care subject to utilization review
Policy / Reference Links:
- BCBSRI Provider Portal: https://www.bcbsri.com/
providers - eviCore Therapy Program Overview: https://www.evicore.com/
solution/physical-medicine
2. BCBSRI – ICD-10 Coding (7th Character “A” Denials)
Update:
- BCBSRI is denying outpatient PT/OT claims billed with injury codes using 7th character “A” (initial encounter)
Clarification:
- For outpatient therapy:
- Care is typically considered subsequent treatment
- Most claims should use 7th character “D” (subsequent encounter)
Policy / Reference Links:
- BCBSRI Medical Policy Library: https://www.bcbsri.com/
providers/medical-policies - ICD-10 Official Guidelines (CMS): https://www.cms.gov/medicare/
icd-10/2024-icd-10-cm
Note: This change is being enforced as a claims editing rule and may not appear as a standalone policy bulletin.3. BCBSRI – Physical Therapy Assistant Modifiers (GP/GO and CQ/CO) – Commercial and Medicare Advantage Plans
Update / Ongoing Enforcement:
- BCBSRI continues to require correct use of:
- CQ / CO modifiers → PTA / OTA services
Key Details:
- Required for:
- Accurate claims processing
- Compliance with Medicare-aligned billing standards
- Errors may result in:
- Denials/ Payment adjustments
Policy / Reference Links: BCBSRI Provider Resources: https://www.bcbsri.com/
4. Medicare Telehealth Extension
Update:
- Medicare telehealth flexibilities for rehabilitation services are extended through December 31, 2027
What This Means:
- Physical therapists may continue to:
- Deliver telehealth services to Medicare patients
- Bill under current temporary provisions – 2 -Way synchronous audiovisual, HIPAA compliant platform
- Coverage specifics (e.g., audio-only) in certain circumstances
Policy Link: CMS Telehealth Guidance: https://www.cms.gov/telehealth
REMINDER:
UnitedHealthcare (UHC) – RIte Care (Medicaid)
UnitedHealthcare (UHC) – RITE Care (Medicaid)
Prior Authorization Requirement – Effective November 1, 2025
Prior Authorization Requirement – Effective November 1, 2025
- Prior authorization is now required for outpatient PT/OT services (excluding the initial evaluation)
- Applies to entire plan of care
- First 6 visits allowed without clinical review, but authorization submission is still required
- Care beyond 6 visits or 8 weeks is subject to medical necessity review
Policy / Reference Link: UHC Provider Resources (RI Medicaid): https://www.uhcprovider.com/