03/12/2024
Periodically, (as often as monthly), we update our lists of services and procedure codes that require Recommended Clinical Review (for some commercial members) to reflect new, replaced or removed codes. These changes are based on updates from our Utilization Management team’s prior authorization assessment, Current Procedural Terminology (CPT®) code changes released by the American Medical Association, or Healthcare Common Procedure Coding System changes from the Centers for Medicare & Medicaid Services.
Accessing RCR Lists
To avoid post-service medical necessity reviews and minimize delays in claim processing, providers should refer to the RCR inpatient services and outpatient code lists on our Recommended Clinical Review Option web page prior to rendering services. If services are performed that do not meet medical necessity criteria, they may be denied for payment and the rendering provider may not seek reimbursement from the member.
Check Eligibility and Benefits
Providers should check eligibility and benefits through Availity® Essentials or their preferred vendor and may also indicate if a service requires a prior authorization or recommended clinical review.
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